EN Exam 2 Study Guide PDF

ED Nursing Role in Research and Evidence Based Practice Definitions Research: provides the scientific basis for the practice of the profession ○ Uses multiple philosophical and theory based approaches and methods ○ Can encompass the work environment, professional development, organizational supports...

ED Nursing Role in Research and Evidence Based Practice Definitions Research: provides the scientific basis for the practice of the profession ○ Uses multiple philosophical and theory based approaches and methods ○ Can encompass the work environment, professional development, organizational supports, and other factors that influence nurse and nursing outcomes Evidence based practice (EBP): process used to review, analyze, and translate the latest scientific evidence ○ Goal is to quickly incorporate the best available research, along with clinical experience and patient preference, into clinical practice, so nurses can make informed patient-care decisions Emergency Nurses Association (ENA) The ENA conducts original research to advance excellence in emergency care The research priorities and accomplishments which are driven by salient issues related to clinical care, input from ENA committees and general assembly resolutions The research trajectory currently includes three main lines of inquiry that establish a body of evidence to support emergency nursing practice through improvements in nurse wellness, delivery of effective patient care, and safer workplaces ENA’s research portfolio impacts the emergency nursing specialty through: 1. Education content that includes online courses and practice resources such as toolkits, topic briefs, and infographics 2. Policy guidelines and legislative advocacy at the local, regional, and national levels 3. Conference presentations, workshops, and peer-reviewed publications 4. Grants and fellowships made available through the ENA Foundation ED Nursing Role in Research and Evidence Based Practice ENA Research Priorities and Contributions to Emergency Nursing 2009-2020: Assessment and treatment of patients with harmful and addictive substance use 2009-2022: ED workplace violence 2010-2018: Staffing of emergency nurses in US EDs 2010-2020: Suicide risk assessment 2012-2021: Managing BH emergencies in the ED 2014-2015: Emergency nurse fatigue 2013-2022: Advanced practice nurses 2017-2021: ED workplace culture and environment Workplace Health Goal: identify and promote evidence-based recommendations to support and sustain a healthy emergency nursing workforce and ED work environment Years Research Priorities Selected Outcomes and Accomplishments 2009-2022 - ED workplace violence (multi-year surveillance surveys on violence against nurses) - Research on nurse bullying - Model of emergency nurse bullying - Peer-reviewed publications - OSHA granting funding for Toolkit and online course development - Toolkit and multidisciplinary call to action - Collaborative guidelines with AONL and IAHSS - Validated grounded theory of nurse bullying (theory development and theory validation) 2010-2018 Staffing of emergency nurses in US EDs - 2014-2014 Emergency nurse fatigue - Foundational research that supported studies on nurse bullying and decision fatigue at triage - Peer-reviewed journal publication 2017-2021 - ED workplace culture and environment - Firearm injury and risk assessment/safety - Impact of cannabis related ED visits - Occurrence of STS and PTSD during Covid-19 pandemic - Peer-reviewed publications (firearms, cannabis, STS, PTSD) - Position statement, webinar, podcast AAP grant funding for online course development Statistically validated formula Staffing guidelines online course Peer-reviewed publication Position statement ED Nursing Role in Research and Evidence Based Practice ENA Research Priorities and Contributions to Emergency Nursing Goal: provide knowledge and evidence-based guidance and education aimed to improve care and health outcomes for patients with BH emergencies Years Research Priorities Selected Outcomes and Accomplishments 2008-2020 Assessment and treatment with harmful and addictive substance use - Peer-reviewed publication - Position statements - Webinar on MAT for opioid misuse/addiction 2010-2020 Suicide Risk Assessment - Peer-reviewed publications - Clinical practice guidelines - Evidence-based recommendations 2012-2021 Managing BH emergencies - 2010-2022 Advanced practice registered nurses - NP competencies development - Peer-reviewed publication - ENA-NACNS collaborative survey of CNS competencies and practices (in press) Peer-reviewed publication Online course Adult and pediatric infographics Podcast episode Responsive Goal: provide time-sensitive evidence to support ENA members in areas other than workplace or behavioral health Ongoing Topics that fall outside of the above two lines of inquiry, generated by general assembly resolutions, national initiatives, and/or collaborations with other organizations - Geriatric ED readiness publication and toolkit - Forensic educational needs for ED nurses publication - Triaging obstetric emergencies publication Meeting the Needs of Hospitalized Older Adults in the ED Aging Today An increasing population ○ >80% of older patients visit ED ○ Average 4-5 chronic diseases ○ 75% visit ED during final 6 months of life A normal process ○ Affects each person in unique ways ○ Does not mean disease NICHE: Nurses Improving Care for Healthsystems Elders Designed to help hospitals improve the care of older adults Provides educational tools and resources to improve care for older adults Fosters a patient and family team approach Age-Friendly 4Ms Framework What Matters ○ Days in hospital, ICU level of care, patient & family experience Mediation ○ Multiple medications, adverse drug side effects Mentation ○ Delirium, dementia, depression Mobility ○ Fall injuries, pressure injuries, pneumonia, DVTs Acute Care of the Older Adult Physical factors Interpersonal factors Social factors Medical treatment factors Meeting the Needs of Hospitalized Older Adults in the ED Aging Body Common Signs of Infection Mental status ○ Assess cognition: screen for delirium ○ Difficulty communicating or inability to make decisions ○ Dementia or delirium may also present as anxiety or confusion Vital Signs Rapid respiratory rate Dehydration Bounding pulse Falling blood pressure Tachypnea Abnormal heart and lung sounds Nutrition and Hydration Evaluate the older adult ○ Dry mucous membranes, tongue furrow/dryness Vitamins & electrolytes ○ Vitamin B deficiency, Vitamin C & E, nutrition-related tissue wasting Meeting the Needs of Hospitalized Older Adults in the ED Oral and Dental Conditions One-quarter of all persons aged 65 or older have no remaining teeth ○ Dental infections ○ Dry mouth & candidiasis ○ Role in aspiration pneumonia Cough & Dysphagia Presence of cough may be an indicator of: ○ GERD ○ Cardiovascular complication ○ ACE inhibitor use ○ Transient ischemic attack ○ Neurologic disease Changes in Bladder Function A clean catch urine specimen may be difficult to obtain Consider organizational policy: ○ Catheterized specimen through sterile intermittent catheterization ○ After changing the indwelling apparatus Changes in Bowel Function The older adult may: ○ Be exposed to pathogenic diarrhea, fluid loss/dehydration Clostridium difficile Diverticulitis Social History Injectable medications Pneumonia or pleural effusion Smoking & lung function Potential Elder Abuse Isolated from friends and family Unexplained bruises, burns, or scars Untreated bedsores (pressure injuries or pressure ulcers) Seems depressed or withdrawn Appears unkempt, underfed, dehydrated, and not well cared for at home or facility Meeting the Needs of Hospitalized Older Adults in the ED Skin Conditions Differences Scabies Bed Bugs Pressure Injury Skin presentation Diffuse intense pruritus, worse at night, live inside skin Rash-red swollen bumps on arms, legs, back, neck, shoulders, etc. Localized damage to skin and/or underlying soft tissue usually over a bony prominence or related to device Injury can present as intact skin or ulcer Environmenta l Prevalent in winter, spreads over great surface area Prevalent in summer, live in furniture Prevalent in patients with reduced mobility, activity, & sensory issues Assessment Check for rash: white, red lines, tunnels or burrows in fold of skin (between fingers, under toenails) Check for linear patterns in groups of 3-4 marks & much larger than scabies mites Check skin integrity q8hrs & prn especially in children and older adults Requires pressure injury risk screening (i.e. Braden) Infection control Contact isolation May be cohorted with any patient, discontinue isolation 24 hrs after initial therapy Standard isolation Block bed or private room, discontinue isolation after bed bug protocol provided No isolation required Patient & family teaching Infested persons, family, close contacts should be treated at same time, regardless if symptoms are not present due to sharing infected towels, bed sheets, etc. May spread within the household (luggage, clothing, infested furniture, etc.) Requires pesticide Encourage frequent T&P, weight shifts in bed or chair, routine skin care Treatment Consult primary team for treatment with medicated creams Usually improves without treatment Consult primary team for treatment of pruritus, prolonged redness, infection Maintain clean & dry skin, safe & efficient transfers, pressure reduction efforts, topical treatment per NYULH protocol Meeting the Needs of Hospitalized Older Adults in the ED Monitor Glycemic Levels Continuous infusions of insulin & glucose Target range: 70-130 mg/dL Ensure education Monitor glucose Titrate insulin Identify, prevent, and correct hypoglycemia Fall Prevention Assess for risk Ensure fall prevention strategies Encourage early mobility Educate patient and family Evaluate effectiveness of interdisciplinary plan of care Sepsis Vital signs Monitor HR, BP, RR Malnourishment Monitor cardiac rhythm, electrolyte status Comorbid heart injury Keep strict intake/output report Poor oral care Ensure proper hygiene, denture fit, risk of aspiration Urinary catheter lines Observe for clots & sediments Mobility restrictions Encourage to turn, position (bed/chair), examine for pressure injuries, note redness, tenderness, skin sloughing, coolness Significant wounds/skin injury Monitor fluid and nutrition status, monitor progress of worsening wound/skin injury Screening Tools Identify specific pathological conditions Determine patient’s ability to follow directions, retain instructions, express self clearly and make decisions Serve as indicator of worsening or improvement over time Meeting the Needs of Hospitalized Older Adults in the ED Geriatric Common Conditions What Are They? Conditions, not diseases Common in the elderly A group of signs & symptoms that occur together ‘geriatric syndromes’ What is Delirium? A disturbance of consciousness Acute onset Change in thinking Patient’s ability to receive, process, store, and recall information is altered Up to 84% of Covid-19 delirium cases undetected Delirium rarely called by name ○ AMS, brain failure, confusion, ICU psychosis, toxic psychosis, acute confusional state, encephalopathy Three subtypes ○ Hyperactive: agitation, restlessness, attempts to remove catheters, and emotionally labile ○ Hypoactive: flat affect, withdrawal, apathy, lethargy, and decreased responsiveness ○ Mixed: combination of hypoactive and hyperactive Delirium gaps ○ A gap analysis identified variations in delirium screening and management ○ Created an interdisciplinary all campus workgroup to develop a standardized delirium screening and management protocol Meeting the Needs of Hospitalized Older Adults in the ED 3Ds Common Features Feature Delirium Dementia Depression Unique features Acute change in mental status - Fluctuating mental status, poor attention, disorganized thinking, altered LOC Chronic and progressive brain disease - Short term memory loss, attentive, poor judgment, wandering Meet strict DSM-5 criteria - History of mood disorder, no alterations in consciousness, anhedonia, prominent low mood, intact memory Duration Days-weeks Months-years Weeks-months-year s after initial diagnosis Cognition May vary from poor to good depending on time of day Will attempt to answer Capable of giving correct answers Speech Often incoherent Word searching Maybe slow Common sleep issues Variable pattern, may have sleep-wake cycle reversal, may differ night-night Restless, agitated or distressed, individual pattern, ‘sundowning’ Early insomnia (falling asleep), middle insomnia (staying asleep), late insomnia (morning wakefulness) CAM Assessment Method (CAM) 1. Acute onset of mental status changes or a fluctuating course 2. Inattention 3. Either a. Disorganized thinking b. OR altered level of consciousness * Incorrect answers includes ‘I don’t know’ and no response or nonsensical responses Ultra-Brief CAM (UB-CAM) Patients with severe lethargy or severe altered level of consciousness are considered delirious and no further screen necessary If able to participate, first step is UB-2 screener ○ Day of week? Months backwards from December Normal response to both = NOT delirious Meeting the Needs of Hospitalized Older Adults in the ED Elder Speak Be mindful of exaggerated affectionate words (sweetie, honey, dear) Avoid use of simplified grammar Team Interventions What MATTERS to patients and families ○ Patient preferences ○ Patient concerns ○ Life goals and philosophies ○ Treatment-specific values ○ Contextual values Process & Outcomes: Goals of Care Conversations Published and Online Resources Respecting Choices Provides training for structured facilitation of advanced care planning Vitaltalk Training for physicians and others leading goals of care conversations VALUE Framework Communication strategies to improve decision making Serious Illness Care A program and guide to improve communication Best Case/Worst Case Communication tool for side by side comparison of options and narrative description of anticipated course with each option Patient Priorities Care Deliberate evaluation of patient values and the development of SMART goals to drive medical decision-making Meeting the Needs of Hospitalized Older Adults in the ED Medication-Related Falls Risk Focus Areas Common and Potential Side Effects Brain Anticholinergics, antidepressants, antiepileptics, antipsychotics, benzodiazepines, hypnotics, opioids → delirium, sedation, blurry vision, dehydration, loss of balance, any of these can worsen overnight Heart Antiarrhythmics and blood thinners → dizziness (may worsen with position changes), risk for bleeding Opioids and muscle relaxants → drowsiness, changes in blood pressure and breathing Stomach Insulin and oral hypoglycemics → feeling light-headed, low blood sugar, sweating, hunger Analgesics → look for blood in stool Bladder and Bowel Antispasmodics and anticholinergics → urinary retention Antihypertensives and diuretics → need to urinate more and frequent bathroom trips Laxatives → loose stools and frequent bathroom trips Opioids → constipation Teach-Back Reminders Ask the patient or caregiver to explain key patient education messages to ensure Teach-Back was effective ○ Tell me 3 potential medication side effects ○ Tell me 3 medication fall prevention measures ○ Tell me 3 goals in getting out of bed to chair & walking safely today Explain & check again if the patient is unable to do teach-back Use the health-literate patient and family teaching guide to reinforce learning Document the use of patient’s response to teach-back Include family members/caregivers, if they are present Meeting the Needs of Hospitalized Older Adults in the ED Best Practice Establish baseline history Ensure a delirium screen and cognitive assessment THINK & treat underlying cause(s) Use non-pharmacologic interventions strategies Involve interprofessional team colleagues Involve patient & family in team plan of care & education Beers Criteria List of medications which are considered potentially inappropriate when given to older patients Neuro Alert What is Stroke? Stroke occurs when there is damage to the brain from interruption of its blood supply Stroke is a medical emergency Types of stroke ○ Ischemic stroke: most common type of stroke, brain’s blood vessels become narrowed or blocked, causing severely reduced blood flow (ischemia) Blocked or narrowed blood vessels are caused by fatty deposits that build up in blood vessels or by blood lots or other debris that travel through the bloodstream, most often from the heart, and lodge in the blood vessels in the brain ○ Hemorrhagic stroke: occurs when a blood vessel in the brain leaks or ruptures ○ Transient ischemic attack (TIA): known as ‘ministroke’ which is a temporary period of symptoms similar to those in a stroke Doesn’t cause permanent damage Caused by temporary decrease in blood supply to part of the brain, which may last as little as 5 minutes It is important to identify the signs and symptoms immediately Stroke team may be activated by any staff member NYU time goals ○ Door to attending physician evaluation (/= 140 mmHg ○ DBP >/= 90 mmHg Preeclampsia ○ Second leading cause of maternal mortality ○ Gestational hypertension with or without gestational proteinuria ○ Signs and symptoms: high blood pressure, proteinuria, vision problems, edema, abdominal pain, weight gain more than 2 pounds per week Most threatening sign of preeclampsia: HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) ○ Nursing interventions Preeclampsia protocol: prevent seizure from happening (pregnant or post-natal) 30 minutes to give anti-HTN (labetalol or hydralazine), fetal monitoring, VS checks Magnesium to prevent against seizure (monitor reflexes, RR) Electronic fetal monitoring ○ Magnesium sulfate infusion 4mg bolus dose over 1 hr and then continuous 2mg/hr Antidote to mag: calcium gluconate Eclampsia ○ Very serious complication of preeclampsia characterized by one or more seizures during pregnancy or in the postpartum period ○ Left untreated, eclamptic seizures can result income, brain death, and possible maternal or infect death ○ Will always go for c-section ○ Signs and symptoms: decreased FHR, seizures ○ Nursing interventions Airway protection, make sure they are breathing (deliver O2 if patent airway, intubate if not) PREGNANT: left lateral position, continuous fetal monitoring until c-section, give mag, treat blood pressure POST-PREGNANCY: ativan to prevent seizures, mag Obstetric Emergencies Emergent Delivery Very rare but can happen Know where your supplies are (emergency delivery kit) Alert the L&D and NICU departments ○ How to activate an emergency delivery Baby and mother always stay together, get ID banded before they go to L&D Steps of emergent delivery 1. Support perineum controlled descent 2. Head resistutes, deliver anterior should a. Check for nuchal cord b. Oxytocin 10U IM 3. Delivery of posterior shoulder 4. Delivery of lower body and umbilical cord 5. Clamp and cut cord at 30-60 seconds Gynecological Emergencies Ruptured Ovarian Cysts Rule out ectopic: do pregnancy test Pain management unless they are rupturing Endometriosis Common complication, uterine lining outside actual uterine wall Diagnostic with US or CT scan Manage pain and bleeding with contraceptives May need DNC or surgery to remove some of the cells Infectious Disease and High Consequence Pathogens Highly Infectious Disease/High Consequence Pathogen A highly infectious disease or pathogen that is transmissible from person to person causes life-threatening illness and presents a serious hazard in the healthcare setting and in the community that requires specific control measures Three Steps For Success 1. Identify a. US based outbreaks: listeria, Covid-19, fungal meningitis, measles, monkeypox b. International outbreaks: ebola, dengue, diphtheria, chikungunya, marburg c. Nursing role i. Identification and isolation 1. Strong triage, symptom awareness, quick isolation ii. Real life anecdote 1. Covid S&S: cough, SOB, fever, chills 2. Travel advisories constantly evolving iii. Current state: we remain hypervigilant to symptoms and masking policies 2. Isolate a. Degrees of isolation precautions b. Starts at universal! i. Handwashing (most important all the way through), gloves c. Progressively increases based on organism/pathogen 3. Inform a. High consequence pathogen hotline 24/7 b. After we identify and isolate the patient, check for next steps and treatment Infectious Disease and High Consequence Pathogens Donning PPE Visually inspect all PPE Disinfect hands inner/routine gloves Coverall Boot covers (only if coveralls without integrated boots) N95 respirator Gown Provided hood Outer gloves/extended cuff Face shield Verify PPE Measles Addendum Most recently, a case was missed at NYULI that resulted in canvasing over 100 staff, patient, and visitors due to possible exposure Top 10 countries: Kazakhstan, Azerbaijan, Yemen, India, Iraq, Ethiopia, Kyrgyzstan, Russia, Pakistan, Indonesia Emergency Department Triage Objectives of Triage Identify patients who need immediate care and treatment Perform a brief primary assessment on all incoming patients Assign an appropriate acuity level Assign a location of care Primary Goal of Triage Decrease morbidity and mortality for all ED patients Primary Assessment Subjective data collection ○ Brief one line statement from patient ○ Precipitating event/onset of symptoms ○ Mechanism of injury ○ Progression of condition from first symptom Objective data collection ○ Airway patency ○ Breathing effectiveness ○ Circulation effectiveness ○ Disability (brief neurological exam) ○ Environmental exposure Assigning an Acuity Comprehensive triage supported by NEA Triage time should take 2-5 minutes JCAHO: talk of sentinel events occur in EDs leading to patient death and/or permanent disability Emergency Department Triage Emergency Severity Index 5-level triage instrument that categorizes ED patients by evaluating both patient acuity and needed resources Algorithm uses 4 decision points to sort patients into one of the five triage levels Category and time ○ Level 1: seen immediately ○ Level 2: seen within 15 minutes ○ Level 3: seen within 60 minutes ○ Level 4: seen within 120 minutes ○ Level 5: seen within 240 minutes Decision Point A: Is the Patient Dying? Is the patient dying? Does the patient require an immediate airway, medication, or hemodynamic support? Does the patient require electrical therapy? Designation of 1 Examples ○ Cardiac arrest, respiratory arrest, agonal gasping resp ○ Severe respiratory distress, O2 sat < 90% ○ Overdose with RR of 6 ○ Hypotension with hypoperfusion ○ Unresponsive ○ Flaccid baby ○ Severe bradycardia/tachycardia with signs of hypoperfusion ○ Anaphylaxis ○ Hypoglycemia with change in mental status ○ Penetrating trauma of head, neck, abdomen, chest requiring life saving intervention Emergency Department Triage Decision Point B: Should the Patient Wait? Is this a high-risk situation? ○ High-risk situation: patient who presents with signs and symptoms or a history suggestive of a serious problem that can rapidly deteriorate without prompt intervention ○ Consider age, past medical history, current medications, RN’s clinical expertise and experience ○ Abdominal Signs and symptoms: severe pain, tachycardia, vomiting blood, BRBPR ○ GU & GYN Signs and symptoms: sudden onset of testicular pain, pregnancy with severe lower quadrant pain, sexual assault of any type (distress) ○ Cardiac Signs and symptoms: chest pain (constant or intermittent), SOB, absence of distal pulse, syncope/dysrhythmias, history of drug abuse Who needs a 10 minute EKG? Anyone presenting with chief complaint of chest pain, chest discomfort, chest pressure Any older patient presenting with abdominal pain above the umbilicus Atypical symptoms (SOB) ○ Respiratory Signs and symptoms: severe SOB, sudden onset SOB, drooling, airway foreign body, esophageal foreign body in child, toxic smoke inhalation ○ Neurological Signs and symptoms: motor or speech deficits (aphasia, aprasia, agnosia, or dysarthria), headache with mental status change, fever or rash, lethargy, seizures ○ Mental health/distress Signs and symptoms: combative, violent, suicidal/homicidal or psychotic, elopement risk, ETOH with trauma, acute grief reaction, prenatal loss, behavioral outbursts Emergency Department Triage Decision Point B: Should the Patient Wait? (Cont.) Is the patient likely to deteriorate? Is the patient confused, lethargic, or disoriented? ○ Chronic dementia and chronic confusion does not meet criteria for ESI level 2 ○ If patient presents confused, lethargic, or disoriented and the patient history is unknown, assume the condition is new Is the patient in severe pain or distress? ○ All patients who have a pain rating of 7/10 or greater should be considered for meeting ESI level 2 criteria ○ Examples of severe pain criteria justifies level 2 10/10 flank pain 80 year old with abdominal pain rated 7/10 30 year old with sickle cell crisis Oncology patient in severe pain Full or partial thickness burn Acute urinary retention Decision Point C: Resource Need How many different resources are needed by this patient? ○ None (level 5) ○ One (level 4) ○ Two or more (level 3) ○ Resources Labs: blood and urine EKG, x-ray, CT, MRI, U/S IV fluid hydration IV, IM, nebulized medications Specialty consultation Simple procedure (lac repair) Complex procedure = 2 (procedural sedation) ○ Not a resource History and physical, phone call to PCP Point of care testing Hep-lock PO meds, tetanus, prescription refill Simple wound dressing Crutches, splints, slings Emergency Department Triage Pediatric Triage: Standardized Approach Infants and children cannot be evaluated through layers of clothing Stranger anxiety School aged children can verbalize cc Adolescents size does not equal maturity Neonate subtle signs: poor feeding, irritability, and hypothermia Infants and toddlers greater risk for heat and fluid loss All children must be weighed Use appropriately sized equipment Hypotension is a late marker of shock Cardiac output in the infant and small child is heart rate related Shock in the Emergency Department Shock Shock: unable to adequately perfuse tissues (all types of shock have this in common) ○ Characterized by build up of lactic acid Stages of Shock Compensated shock: stage 1, compensating for initial insult that has occurred ○ Do not pick up on subtle changes ○ Sympathetic nervous system kicks in (increased HR, increased RR, vasoconstriction --> increased BP) ○ May have a drop in BP but not low enough to evoke response, what is this person's normal BP? HTN at baseline can mean normal BP is low for them ○ Signs and symptoms Early signs: low BP compensated by increased HR Compensatory signs: increase ADH, vasoconstriction, increased HR, low PH ○ Assessment findings Anxiety, confusion, restlessness Narrowing pulse pressure Increased HR - bounding pulse Decreased urine output Decompensated shock: progressive, hypotensive shock ○ Signs and symptoms: tissue hypoxia, cold extremities, oliguria, CNS changes, low BP ○ Assessment findings Change in mental status - AMS Decreased BP, narrowing pulse pressure, increase HR (weak pulse), increased RR, cold/clammy skin Irreversible (refractory) shock: death is imminent, patient may be unconscious, hypotension severe, HR begins to decrease ○ Damage is done, organs will not recover ○ Signs and symptoms: multiorgan failure, low PH, death ○ Assessment findings Obtunded, unresponsive, comatose Profound decrease in BP, narrowing pulse pressure, decreased HR (weak pulse), slow/shallow respirations Cyanosis, petechiae Shock in the Emergency Department Types of Shock (think pump, pipes, fluid) Hypovolemic shock: problem with the fluids (hemorrhagic or non-hemorrhagic) ○ Etiology: burns, diabetes insipidus, decreased body fluids, hemorrhage, GI loss (bleeding, vomiting, diarrhea), diuresis ○ Preload decreases, contractility and afterload increase ○ Management: stop the bleeding, give oxygen, start IV fluids ○ Trauma’s lethal triad of hypothermia Cardiogenic shock: problem with the pump (arrhythmia, severe CHF, etc.), not getting things where they need to be ○ Etiology: MI, myocardial ischemia, blunt cardiac trauma, sustained cardiac arrhythmia, valve dysfunction, end stage cardiomyopathy ○ Signs and symptoms: tachycardia, anxiety, delirium, increased preload, pulmonary congestion, decreased cardiac output, dusky skin color, decreased BP, narrow pulse pressure, oliguria, dyspnea ○ Management: airway management, reduce cardiac workload (decrease preload, decrease afterload), treat arrhythmias, surgical management Diuretics to decrease preload Decrease after-load if concurrent HTN (be careful with vasodilators bc you don’t want to bottom out BP) Balloon pump to decrease systemic resistance heart has to pump against Inotropes to make the heart beat better Shock in the Emergency Department Types of Shock (think pump, pipes, fluid) (Cont.) Obstructive shock: cardiac output and tissue perfusion are inadequate because of ventricular filling resistance ○ Heart cannot expand to contract adequately or blood cannot get there (PE) ○ Typically from tension pneumothorax, pericardial tamponade, superior vena cava syndrome, etc. ○ Management: stop obstruction (i.e. needle decompression, pericardiocentesis) Distributive shock: most common (includes sepsis), problem with the pipes (blood vessels), lose tone to blood vessels, capillaries are hyperpermeable; heart is working and adequate volume but cannot get the fluid where it needs to go ○ Anaphylactic shock: acute life-threatening hypersensitivity reaction Give epinephrine in thigh (IM) - then steroids and diphenhydramine ○ Neurogenic shock: vasodilation due to loss of sympathetic output Lose tone of the pipes, cannot send sympathetic nervous system to respond Treat spinal cord injury, use pressors and inotropes to increase cardiac output ○ Septic shock: last stage of sepsis ○ NOTE: giving fluids with distributive shock will not solve the problem, problem is with the pipes Management of Mass Casualty Incidents New York City MCIs in Recent History 2008 2013 2014 2017 2018 2020 2022 2022 Midtown Crane Collapse Metro North Train Derailment East Harlem Gas Explosion West Side Highway Ramming East River Helicopter Crash Subway Fire Bronx High Rise Fire Brooklyn Subway Shooting Mass Casualty Program Serves to improve the preparedness of the Manhattan main campus to activate the MCI protocol and effectively manage a large influx of patients Mass decontamination ○ A critical and complex function within mass casualty response ○ Coordinated via a supplementary NYULH response protocol Existing Capabilities MCI and decon response protocols Notification and activation processes Infrastructure and equipment 65 member decon team NOTE: FDNY determines MCI level Management of Mass Casualty Incidents Activation Procedure 1. Follow instructions of ED Flow Coordinator 2. Close ED walk-in and EMS entrances (close ambulance bay to all motor vehicles) 3. Decompress Kimmel Core a. Rapidly admit ED patients to inpatient units b. Move Kimmel Core patients to Tisch Core c. Ensure continued cafe hand-off for patient care 4. Move MCI equipment cards from storage to the triage area a. Open the roll-up door and roll carts into the Kimmel ambulance entrance b. Close the roll-up door after all carts have been moved 5. All arriving patients enter through the Kimmel ambulance entrance a. If needed, perform mass decontamination and remove patient clothing b. Triage patients using the START algorithm and colored acuity tags c. Walk minor/ambulatory (green tag) patients to Tisch Core d. Move immediate (red tag) and delayed (yellow tag) patients to Kimmel Core) Preparedness Activities Regular planning team meetings Hands on mass decontamination trainings Discussion-based and operational exercises ○ April Radiation Injury Influx Tabletop ○ December MCI Full Scale ○ January 2023 Executive Tabletop Special event planning ○ Structured walkthroughs ○ Proactive decon team staffing Management of Mass Casualty Incidents Training & Education START Triage Training ○ Emergency department nursing staff ○ Quarterly: 10-15 minute sessions on each shift Hands on decontamination training ○ Open to all NYULH staff ○ Four trainings offered annually; half and full day Structured walkthroughs ○ Frontline staff in key departments ○ Regularly and prior to high-risk events; 30-60 minutes What Is START Triage? Rapid and streamlined triage with 2 specific goals 1. Speed: move the most patients possible, as safely as possible 2. Identify who need the most help, now Simple Triage And Rapid Treatment START Triage Algorithm Management of Mass Casualty Incidents JumpSTART Pediatric Triage Slightly different start triage for peds Peds pts have a higher degree of resilience and are more likely to survive with long period of apnea Drills and Exercise Operational ○ Decon team comms drills ○ Functional exercise Focus on triage and decanting Validate working group efforts ○ Full scale Decontamination scenario Full donning/doffing/decon of actors Test all response components Discussion-based ○ HRO crisis management drills ○ Executive TTX (January) Management of Mass Casualty Incidents Mass Casualty Incident Full Scale Exercise Record emergency department volume on Dec 6th (127 ED patients, 54 awaiting bed requests) Improvised explosive device (IED) scenario in Midtown Triaged and simulated placement of 30 patient actors Managed arrival of 12 actors portraying family and friends 27 participating departments Takeaways include need for enhancements to triage, decanting, and surgery prioritization “Up to 1/3 of patients with ‘potentially survivable wounds’ could have been saved” Trauma Trauma Nursing Care Trauma team structure and roles Communication Debriefing Trauma? Unintentional and intentional injuries caused by the sudden application of external force to the tissues ○ Synonyms: injuries, wounds, casualties, assaults, crashes, collisions, wrecks, homicide, falls, etc. Trauma is the leading cause of death in individuals ages 1-44 years old Common etiologies 1. Motor vehicles 2. Falls 3. Firearms 4. Fire and burn injuries Who Is A Trauma Patient? Physiologic Criteria Anatomic Criteria Mechanism of Injury Criteria Patient/ Environmental Criteria Systolic BP < 90 mmHg - Penetrating injuries to the head, neck, torso, or proximal extremities - Open or depressed skull fracture - Unstable chest wall (flail) - Paralysis - Amputation above the wrist or ankle - Crushed, degloved, or mangled extremities - 2 or more obvious femur or humerus fractures - Pelvic fractures - Falls > 20 ft → Pediatric: > 10 ft or 2-3 times their body height - Older adults: risk of injury increases after age 55 → Love impact mechanisms (ground level falls) might result in severe injury - Auto vs. pedestrian or bicycle: pt was thrown, run over by a vehicle traveling > 20 mph - Motorcycle or ATV collision - High risk motor vehicle collision → Significant passenger space intrusion (> 12 inches into occupant site or > 18 inches anywhere else) → Ejection from vehicle → Death of someone in the vehicle → Telemetry data consistent with high risk for injury - Age < 15 or > 55 years → Transport children to a peds capable trauma center - Pregnancy > 20 weeks - Significant comorbid medical conditions (i.e. DOAC, ERSD) - Burns (according to ABA criteria) Time-sensitive extremity injuries (i.e. amputation, globe rupture) - EMS judgment RR < 10 or > 29 → Pediatric: < 20 in kids less than 1 year old GCS < 14 Trauma The Trauma Assessment Initial assessment: to identify and treat or stabilize life threatening injuries in an effective and timely manner ○ Preparation and triage ○ Primary survey (ABCs) ○ Re-evaluation ○ Secondary survey ○ Re-evaluation and post-resuscitation care TDAP ○ Definitive care or transfer to an appropriate trauma center Across the Room Assessment First of any emergency Team has the chance to gather informed observational data ○ Are they bleeding? (uncontrolled hemorrhage) ○ Are they breathing independently? (breathing patterns/concerns) ○ Appearance (mental status? unconscious?) Can modify your ABC’s based on your observation ○ For example: patient with uncontrolled bleeding should start with C (circulation) then proceed to A and B Primary Assessment: A-J Mnemonic for Trauma Nursing Process (TNP) Airway/alertness with C-spine stabilization Breathing and ventilation Circulation and control of hemorrhage Disability Exposure and environmental control Full set of vital signs and family presence Get monitoring devices and give comfort ○ LMNOP: Labs, Monitor, NGT or OGT, Oxygenate and ventilation analysis, Pain assessment History and heat to toe assessment Inspect posterior surfaces Just keep re-evaluating Trauma Amputation Stop Disruption of continuity of extremity or other body part Part should be wrapped in sterile gauze, placed in plastic bag, transported on top of cold pack Do NOT pack part directly in ice Do NOT let part freeze the Bleed Apply pressure with hands Apply dressing and press Apply tourniquet ○ Potassium can be released when tourniquet is released ○ Calcium gluconate to offset potassium Patient Experience: The Nursing Bundle Patient Experience Nursing Bundle Leader rounds Bedside shift report Hourly rounding Bedside Shift Report IPASS Illness severity and introduction ○ Introduce and manage up oncoming RN ○ Performs ITRACE ○ Is the patient stable or ‘hot spot’? Patient information ○ Review current therapy and significant shift events including an assessment utilizing a systems approach to report pertinent issues Action list ○ Outline medications, pending studies, treatments, consults ○ Outstanding tasks Situational awareness ○ Highlights conditions which require close awareness, prioritization, and/or escalation Synthesis of information ○ Outgoing RN allows time for questions and clarification ○ Oncoming RN synthesizes report; reviews with patient Purposeful Rounds Using the 5 P’s Pain: Do you have any pain? How can I help to improve your pain? Personal toileting: Can I assist you in using the bathroom? Positioning: Are you comfortable the way you are? Do you need to be repositioned? Personal items: Do you have everything you need? Can I move any of your personal belongings closer? Presence: We are here for you. Let us know if we can do anything else Patient Experience: The Nursing Bundle Building and Empathy Statement Intro Link Name the Emotion I can imagine That This is very frustrating I can see Why You’re anxious I can hear How Upset you are It sounds Like You’re very excited You look Like You are more comfortable Patient Experience Workflows to Enhance Service Recovery ED proactive rounds Hospitality Continuity Enhancing the patient experience Spiritual care support Pediatric support Patient Safety in the Emergency Department Patient Safety and HRO: Why is it Important? Eliminate preventable harm Improves patient safety, staff engagement, and organizational sustainability Patient Safety Priorities in the ED Imperative to establish a culture that supports systems approach to patient safety Event reporting Electronic health record (EHR) Medication safety Transitions of care and admission Discharge Benefits of HRO (High Reliability Organization) Transforms cultures Improves systems approach Empowers workforces Increases mindfulness prevention or risk/safety events Systems become more reliable, resulting in decreased harm Improvement in clinical outcomes Patient and family experience(s) improves Framework for Safe and Reliable Care Patient Safety in the Emergency Department 5 HRO Principles HRO Characteristic s Brief Description of Reliability Under Routine Conditions Related Components of the IHI’s A Framework for Safe, Reliable, and Effective Care Preoccupation with failure Leaders and teams are preoccupied with the reliability of processes. The fault mindset is that there are no good processes in place, or processes are in place but they are not reliable. Therefore, processes must be continuously improved. - Leadership - Reliability - Improvement and measurement - Continuous learning - Transparency Reluctance to simplify Leaders and teams are reluctant to interpret variation as normal. Processes have become complex, resulting in wide variation in performance and results. Reducing variation is essential. - Sensitivity to operations Leaders and teams know the common failure modes in routine processes. - Leadership - Psychological safety - Accountability - Improvement and measurement - Continuous learning Commitment to resilience Leaders and teams are committed to timely feedback (with data and action to the frontline) about processes and outcomes. There is commitment at all levels for timely action when there is suboptimal performance. - Leadership - Psychological safety - Accountability - Teamwork and communication - Improvement and measurement - Continuous learning - Transparency Deference to expertise Processes need to be designed by the experts (those with the most relevant training in that area). Their expertise is most essential for designing processes, not necessarily for executing processes. Experts include those on the frontlines closest to the process. - Leadership - Psychological safety - Teamwork and communication - Improvement and measurement - Continuous learning Leadership Reliability Continuous learning Transparency Patient Safety in the Emergency Department 3 HRO Behaviors 1. Everyone makes a personal commitment to safety 2. Everyone is accountable for clear and complete communication 3. Everyone supports a questioning attitude Personal Commitment to Safety ARCC: Ask, Request, Concern, Chain of command ○ Ask: first ask a question ○ Request: if a team member does not modify their plan request a change ○ Concern (CUS): if they do not modify their plan, express your concern about the situation Concerned, Uncomfortable, Safety issue ○ Chain of command: escalate through chain of command STAR: Stop, Think, Act, Review ○ Stop: pause to focus attention on the task at hand ○ Think: understand WHAT is to be done, plan your actions, decide what to do if the unexpected occurs ○ Act: carry out the planned task ○ Review: verify you get the expected results Clear and Complete Communication Debrief: brief team meeting to plan forward, improve situational awareness, and adjust editing plan as needed ○ What did we do well? What did we learn? What do we want to do differently next time? Huddle: teamwork SBAR for escalating a concern ○ Situation ○ Background ○ Assessment ○ Recommendation Patient Safety in the Emergency Department Nursing Teamwork Survey Subscales Shared mental model: collective mindset Team leadership: structure, direction, and support provided by formal leader and on the part of team members Team orientation: belief in the importance of team goals over individual member goals Mutual trust: belief that team members will act in ways that promote the aims of the team Backup behaviors: team members helping one another with their tasks and responsibilities Questioning Attitude Stop: if you are uncertain about what you are about to do, if you have questions, if someone raises a concern of question Resolve: review your plan, resolve the concern, reassess your actions Key Concepts for Success Communication: deference to expertise Improvement models: reluctance to simplify Continuous learning: sensitivity to operations Accountability: commitment to resilience Transparency: preoccupation with failure Organizational Leadership Maturity Levels of HRO Generative: organization wired for safety and improvement ○ Leaders create high degrees of psych safety and accountability Proactive: playing offense - thinking ahead, anticipating, solving problems ○ Leaders model the desired behaviors to drive culture of safety Systematic: systems in place to manage hazards ○ Training and support exists for building clinical leadership Reactive: playing defense - reacting to events ○ Episodic, completely dependent on the individual clinician Unmindful: no awareness of safety culture ○ Absent for the most part Patient Safety in the Emergency Department Practice Pearl: Incorporate Bedside Handover Into Your Practice Bedside handoff improves staff’s teamwork by giving nurses the opportunity to work together at the bedside, ensuring accountability Bedside handoff must occur at each transition of care, including break coverage The bedside handoff process acknowledges the patient as a partner and reassures the patient that the nurses work as a team Knowing that nursing staff is getting the information needed to facilitate care decreases patient and family anxiety and improves patient experience Bedside handoff decreases medication errors, sentinel events, and nurse overtime Pediatrics Pediatric Triage: Standardized Approach Appearance, work of breathing, circulation ○ Appearance: tone, interactiveness, consolability, look/gaze, speech ○ Work of breathing: breath sounds, positioning, retractions, flaring, apnea/gasping ○ Circulation: pallor, mottling, cyanosis Airway, breathing, circulation, disability, exposure (ABCDE) Pertinent history, vaccination Vital signs Fever Pain Infants and children cannot be evaluated through layers of clothing Stranger anxiety School aged children can verbalize CC Adolescents size does not equal maturity Neonate subtle signs: poor feeding, irritability, and hypothermia Infants and toddlers are at greater risk for heat and fluid loss All children must be weighed Use appropriately sized equipment Hypotension is a late marker of shock Cardiac output in the infant and small child is HR related Pediatric High Risk Situations Seizures Accessory muscle use, retractions, nasal flaring Severe sepsis Dehydration, ingestions Burns, suspected child abuse Fever in newborn Head trauma Pediatrics Examples of ESI Level 2 for Pediatrics Syncope/altered mental status Immunocompromised patient with fever Hemophilia with possible acute bleeds Febrile neonate Hypothermic infant Suicidality R/O meningitis Seizures with prolonged postictal period Respiratory distress Pediatric Vital Signs For children under the age of 3, vital signs used are pulse, RR, SpO2, and temperature Are vital signs outside the accepted parameters for age? Consider triaging up to level 2 Pediatric Fever Danger zone is age dependent O2 saturation < 92 Age Temperature ESI Level 1-28 days > 100.4 F 2 1-3 months > 100.4 F Consider 2 3-36 months > 102.2 F Consider 3 Pediatric Sepsis Fire Criteria Temperature abnormality (< 36o C OR 38o C) AND any HR/RR abnormality OR blood pressure triggers Pediatrics Respiratory Sounds Stridor: upper airway obstruction, high pitched in croup and foreign body aspiration ○ Low pitched and muffled in epiglottitis Wheezing: caused by lower airway obstruction ○ Bilateral wheezing suggest reactive airway diseases such as asthma or bronchiolitis ○ Unilateral wheezing suggests foreign body aspiration Decrease, absent, or unequal breath sounds: caused by airway obstruction, pneumothorax, hemothorax, pleural effusion, infiltrates or atelectasis Audible expiratory grunting: caused by early closing of the glottis during exhalation with active chest wall contraction ○ Increase expiratory airway pressure, prevents airway collapse, and creates positive and expiratory PEEP ○ Grunting is a sign of severe respiratory distress Differences for Pediatric Patients Infants breath predominantly using abdominal muscles ○ Any pressure on the diaphragm may impede respiratory effort Less compensatory reserve ○ The younger the child, the more susceptible to respiratory distress and failure Metabolic rate in infant is approximately 2x that of an adult ○ Increased metabolic rate increases the need for oxygen ○ Hypoxia occurs more rapidly in respiratory distress ○ Anything that increased metabolic rate (i.e. fever) contributes to respiratory demands Thin chest wall ○ Breath sounds are easily transmitted and may be misleading Pediatrics Respiratory Distress Signs and symptoms ○ Tachypnea and dyspnea ○ Tachycardia ○ Irritability or lethargy ○ Nasal flaring ○ Grunting respirations ○ Head bobbing ○ Tracheal tugging ○ Use of accessory muscles ○ Intercostal and suprasternal retractions ○ Dysphagia ○ Abnormal breath sounds ○ Altered level of consciousness ○ Strider ○ Tripod position Differences between the adult and pediatric airway and lung tissue ○ Children and infants have fewer and smaller alveoli More susceptible to collapse due to lower elastic recoil ○ Less tidal volume and lower residual capacity leads to minimal reserve of oxygen ○ Proximal and distal airways are smaller Pediatrics Croup Viral respiratory illness - caused by parainfluenza Most common in late fall/winter to kids under the age of 3 Involves inflammation and edema of the tissue surrounding the vocal cords and trachea Symptoms worse at night Home remedies include humidified air (warm shower mist) followed by cool air (exposure to night air) creates a drastic clinical improvement History ○ Gradual onset of symptoms over one to two days ○ History of recent upper respiratory infection ○ Cough worse at night Signs and symptoms ○ Usually low grade fever ○ Hoarse voice ○ Inspiratory stridor ○ Barky cough Treatment ○ Provide cool mist or humidified air ○ Ensure adequate PO fluid intake ○ Administer racemic epinephrine via nebulizer and steroids as ordered Child should be observed at least 2-4 hours after administration to monitor for rebound effect which may be seen from this medication Pediatrics Appendicitis Most common childhood illness that requires emergency surgery Peak ages 15-24 years old Starts with obstruction of the appendiceal lumen, secondary to fecalith ○ Necrosis of the wall of the appendix ensures, then perforation and spillage of stool into the peritoneal cavity causing peritonitis ○ Early diagnosis is key ○ Perforation occurs in 20-40% of children ○ Typically with perforation pain has been occurring longer than 36 hours History ○ Less than 36 hours of pain, anorexia, N/V ○ Early: colicky or persistent periumbilical pain then shifts to RLQ ○ Low grade fever is common ○ Changes in stool pattern Physical ○ Tenderness over Mcburney’s point ○ Positive Psoas sign (pain with resistance on leg) ○ Rovsing's sign (palpation in LLQ causes pain in RLQ) ○ Involuntary guarding ○ Rebound tenderness Treatment ○ NPO, IV hydration ○ Blood work ○ Surgical consult ○ Ultrasound or CT ○ Antibiotics ○ Surgery Pediatrics Pyloric Stenosis Signs and symptoms ○ Usually start between 3-5 weeks of life ○ Forceful, projectile emesis after every feeding ○ Small oval mass in upper left quadrant of the abdomen Hypertrophic pylorus which causes the obstruction at the outflow tract of the stomach Because there is minimal absorption of fluid, the infant is at risk of dehydration Treatment: pyloromyotomy Intussusception Intestinal folding Signs and symptoms ○ Start suddenly ○ Child draws up the knees up toward the chest ○ Very fussy ○ Stools mixed with blood and mucus - jelly-like stools Treatment: air/barium enema ○ Surgical intervention if enema does not work Nursemaid’s Elbow (Radial Head Subluxation) When a ligament slips out of place and gets caught between two bones in the elbow joint Common causes: lift by the arm, swinging a child, child rolling over on the arm during sleep/playing Signs and symptoms ○ Child will not move the arm and hold the arm straight or with a slight bend in the elbow ○ Does not make the elbow swollen or bruised Treatment: reduction maneuver called Supination technique ○ While holding the arm supinated the elbow is then maximally flexed ○ The provider’s thumb applies pressure over the radial head and a palpable click is often heart with a reduction of the radial head Pediatrics Comfort 5 Bundle 1. Partnership: you know your child best, tell us what comforts and calms your child 2. Positions: comforting ‘hugs’ and other positions to help children feel more in control 3. Numbing options: numbing cream and other options can help to reduce pain 4. Distractions: use music/singing, pinwheels, bubbles, and toys for child to focus on 5. Sucrose: breastfeeding or sugar water help comfort babies under 12 months IV Insertion in Pediatric Patients Minimize pain of the procedure (Comfort 5) A good HOLD is key Utilize positions of comfort Distraction by a child life specialist, if available Use all securement devices ○ Stat-lock, arm board, etc. Utilize vein illuminators, if available Positioning a child for IV insertion ○ Laying down ○ Sheet blocks child’s view ○ Child’s elbow kept straight & mechanical disadvantage ○ Assistant stabilizes child’s hand and retracts skin LifeFlow Hand-operated rapid infusion divide that allows healthcare providers to deliver blood or fluids quickly and effectively 10 mL per push/squeeze of device One patient per infuser, equipment should stay with the patient Deliver 500 mL of fluids in less than 2 minutes Does not pull back from the patient