Emergency Nursing PDF

**Ch. 67 - Emergency Nursing (pg. 5741)** **Emergency Nursing** - **Emergency**: **what the patient believes to be an emergency** - **Issues in Emergency Nursing** → legal issues, staffing, health & safety risks to ED staff (pts with weapons of violence from family or pts, exposure to...

**Ch. 67 - Emergency Nursing (pg. 5741)** **Emergency Nursing** - **Emergency**: **what the patient believes to be an emergency** - **Issues in Emergency Nursing** → legal issues, staffing, health & safety risks to ED staff (pts with weapons of violence from family or pts, exposure to communicable disease), providing holistic care in a fast-paced environment, technology (most EHR have slowed progress down and negatively affect documentation), **issue of consent** (pt with altered LOC or children), **capacity is always the greatest challenge** - ER works through bundle payments nowadays - **What does it take to be an ER nurse?** - Time management, assessment skills, critical thinking, clinical nursing judgment, cool/calm/collected, assertiveness, resilient and resourcefulness - **KNOW EMTALA:** According to the Emergency Medical Treatment and Active Labor Act (EMTALA), every ED with a Medicare provider agreement must perform a medical screening examination on all patients arriving with an emergency medical complaint if their acute signs and symptoms could result in serious injury or death if left untreated - **ER are historically money "losers"** - **MC visits, chart 67-1→ abdominal pain, chest pain, cough, fever** - **People with insurance are MORE likely to abuse ER services than those who do NOT have insurance** - Priorities: **Safety \#1** - **KNOW Avoidance of Sentinel events, pg 5747:** - Unanticipated events that cause the patient harm - **MC: delays in care and medication errors** - Root cause for Sentinel events: nurse staffing patterns, patient volume, and speciality availability - Ex: A red falls risk pt is on the commode, they fall and hit their head and die - **Family Interventions, pg 5747, chart 67-2:** - **The family is kept informed, where the patient is, how they are doing, and the care that is being given** - **Helping Family cope** → privacy, talk to fam together, reassure everything possible was done, avoid euphemisms like "passed on", encourage viewing of body, avoid giving unnecessary info (like pt was drinking) - Keep family in the loop -- presence during resuscitation **Triage (trier/"to sort")** → determines severity of illness from resuscitation to minor, ranks from level 1 (most urgent/resuscitation) to level 5 (least urgent/minor), - **Triage nurse**: collect additional crucial baseline data: full vital signs including pain assessment, history of the current event and past medical history, neurologic assessment findings, weight, allergies (especially to latex and medications), intimate partner violence screening, and necessary diagnostic data. - Also in charge of the patients in the waiting room - **Sudden onset is more important in triaging** - Problem: high volume and low flow (lecture) - - if left untreated, could result in death - serious but not gonna be dying soon **KNOW Airway obstruction, pg. 5757,** Life-threatening, can lead to brain death quickly - - Patho: during an airway obstruction O2 of the blood decreases rapidly b/c obstruction of the airway prevents entry of air into the lungs. O2 deficient results in unconsciousness and death follows - RF: - In older adults: mental dysfunction (dementia, intellectual disability) - In adults: bolus of meat is the MC cause of airway obstruction - S/sx: **cannot speak, breath, or cough**, choking, refusing to lie flat, inspiratory & expiratory stridor, labored breathing, flaring nostrils, increased anxiety, accessory muscle use, restlessness, retractions, confusion, cyanosis**, universal distress signal (pt clutches the neck bt/ the thumb and fingers)** - AMS & LOC w/ late signs (not in book) - Causes: aspiration of foreign bodies, anaphylaxis, viral or bacterial infection, trauma and inhalation or chemical burns, Opioids (not in book) - Management: **PRIORITY is to establish an airway** - The patient is encouraged to cough forcefully and to keep coughing and breathing as long as good air is exchanged (book) - Need to know if airway is patent - Head tilt w/ chin lift + listen/check for breath sounds - If unconscious, an oropharyngeal airway is placed into the lower posterior pharynx - After the obstruction is removed, rescue breathing is initiated - Maybe require ET tube and mechanical ventilation or resuscitation bad is used **Hemorrhage, pg. 5761 →** main cause of shock d/t hypovolemia - **Priority → stop the bleeding and replace fluids** - **Hold pressure on artery above spot of bleeding or direct pressure** - **Management**: 2 Large Bore IVs, Oxygen, Volume (crystalloids), Pressors, Blood and Blood Products (packed RBC, for significant bleeds), may get clotting factors - **Blood analysis typing & crossmatch of the blood is obtained**; can give platelets to clot - IV fluids → NS or Lactated Ringers - May need massive transfusion of warm blood (prevent hypothermia) - **S/sx of hypovolemic shock (is this supposed to be s/s of hemorrhage?)**: tachycardia, **low BP, cool/moist skin, rigid abdomen,** decreased LOC, delayed cap review, decrease UOP - Any time there's an acute situation or sudden onset of something (chest pain or abdominal pain), think about hemorrhage. - **Internal hemorrhage s/s:** tachycardia, falling BP, cool and moist skin - Keep pt in supine position **Wounds, pg. 5764, chart 67-3 (definition of terms)** - Goals: Restore physical integrity and function, **minimize scarring**, prevent infection - Patients experiencing **intimate partner violence** or trauma my need the photographs later to visually describe the extent of the injury (book) - Determine when and how wound occurred (important to document wounds accurately) - Use aseptic technique and monitor for sensory/motor/vascular changes, may utilize sutures or staples - **Management:** - Preparation for Wound Care: clip/shave hair, Clean with NS or polymer agent (ex: Hibiclens/Shur-Clens), assist with debridement or suturing - Primary closure: sutures or stapled - Delayed primary closure: is indicated if tissue is lost, or if there is a high potential for infection, wound is old (48hrs or \>) (not in book) - Ex: **If you have a tibia sticking out of your right leg, what is the immediate action?** - Cover wounds with dampen sterile gauze and stabilize the limb by tying legs together - Tx: tetanus prophylaxis is given as prescribed **Trauma, pg. 5765**: Unintentional or Intentional wound or injury (Stabbing, GSW, MVA) - Pt arrival → **primary survey (ABCDE survey) & stabilize ABCs** - When clothing is removed from the pt who has experienced trauma, the nurse must be careful not to cut through or disrupt any tears, holes, blood stains on the clothing if criminal activity is suspected - **RN responsible** - assessing, managing & monitoring VS, draw labs, IV access, warmth, & documenting - **Document:** anything the pt tells you about the incidence in their OWN words and with quotation marks, **need to know mechanism of injury, time of the event, and know if it is due to criminal event** - **KNOW: Multiple Trauma** → single catastrophic event that causes life-threatening injuries to **at** **least TWO organ systems** - Morality is related to what systems are involved - **Airway/breathing/ventilation, control hemorrhage, prevent and tx hypovolemic shock, rapid trauma assessment (assess for head and neck injuries), splint and immobilize** - **2nd exam: full** physical assessment - MVA: **worry about broken pelvis (due to heavy bleeding that can occur)** and GU injury - Level 1 hospitals: trauma surgery in house 24/7 - **ALL deaths of trauma patients MUST be reported to the medical examiners** - **Criminal Evidence** → remove clothing, don't cut a bullet hole/stab wound, each item of clothing in an individual paper bag, label everything w/ your name, date & time, keep up with it & directly hand it off to police - **If a trauma pt dies** → we must report to medical examiner & leave all tubes in place, clean & prep for family, bag hands - **Ex: A trauma pt that is on the side of the road, no bone sticking out, pt is unconscious. What is something the EMT may do that puts pt at risk of hypothermia?** - Remove clothes + apply non-warm oxygen **Intra-Abdominal Injuries** - Assess abdomen → A/B/C - Blunt force or penetrating - Impalement → will come to the ER with the implement - **KNOW** **Organ most commonly injury is the LIVER, due to its size and anterior placement in the RUQ** - **Lab work you will need to obtain**: - **UA**: GU injury - **H/H (CBC):** bleeding - **Amylase/Lipase**: injury to liver - **WBC**: for infection - **KNOW Blunt force trauma usually involves injury to the chest, head, extremities, and can be difficult to find if the patient has distracting injuries** (lecture) - **KNOW** s/s of abdominal pain, rigidity **(ADD THIS FROM RECORDING)** - Assessment of the abdomen: auscultation of bowel sounds, abdominal distention, involuntary guarding, pain, muscular rigidity, rebound tenderness - Dx imaging needed: CT, US - Medication → small dose of opioids - Management - **NPO**, NG Tube for decompression, Tetanus, Broad Spectrum Abx, cover open wounds, watch for s/sx of shock **Environmental Emergencies → Heat Stroke (an acute medical emergency caused by failure of the heat-regulating mechanisms of the body)** - Patho: heat induces coagulopathies and damage to the liver, heart, and kidneys - At risk for heat stroke→ elderly or very young, chronic conditions, certain medications (Beta Blockers, Diuretics) - MC cause: nonexertional, prolonged exposure to an environmental temperature of greater than 102.5 F (book) - **S/sx** → **confusion/altered menstrual status, hot dry skin**, **cerebral edema (seizures, delirium, coma),** Na and K+ levels are low and need replacement, high body temp, tachypnea, tachycardia - **Management → need to be cooled off slowly, (\< 102 F w/in 1 hour)** - Remove clothing, ice packs in axilla or groin, IV access & fluids, cold bath, cooling blankets, continuous core temp monitoring, strict I&O, monitor cardiac rhythm, frequent reassessment of LOC and VS - **Due to hyponatremia and hypokalemia** → replace Na & K, typically low. - **Gerontologic considerations:** their circulatory system are unable to compensate for stress imposed by heat, they cannot perspire, diminished thirst mechanism, - Ex: Older pt who is outside moving lawn who has heat stroke, what is the immediate action? - SLOWLY decrease his temp with cooling blanket **Environmental Emergencies → Heat Exhaustion** - S/sx → **anxiety, profuse sweating**, muscle weakness, warm and moist skin, tachycardic, minor confusion, muscle cramps, orthostatic hypotension - Body temp: 102 F - Causes: inadequate fluid intake - **Management**: fluids, Na & K replacement, limit caffeine & alcohol, sunscreen, prevention, strict I&Os - **Gerontological considerations:** Decreases ability to sweat, deceases thirst mechanism, decreases ability to concentrate urine - **Prevention Chart 67-6, pg. 5777** - Maintain adequate fluid intake, wear loose clothing, do not have physical activity during the hottest part of the day - Limit caffeine and alcohol **Environmental Emergencies → Frostbite, 5780** - Cause: long term exposure to cold - **RF:** occupational or recreational exposure (skiing), Homeless, Mental Health Disorders, Alcohololics, Smokers, mobility issues - **First degree (erythema) to fourth degree (full-depth tissue destruction)** - **Clinical manifestations** - **KNOW Commonly on hands, feet, noses, ears, and cheeks** - Frozen extremity may be hard, cold, and insensitive to touch and may appear white or mottled blue-white - Once black: usually allow auto amputation (not in book) - **Assessment**: get the **COLD WET** stuff off the patient immediately - **Intervention:** controlled yet rapid rewarming is instituted for 30-40 mins, during rewarming you may give analgesic for pain - Once warmed, the part is protected from further injury and is elevated to control swelling, hourly active motion of an affected digits is encourage to promote maximal reposition of function to prevent contractures - Temperature must be \< 9 degrees F - **Management:** - **Do not run under hot water, massage it, or put wet gauze on the hands.** - Remove restrictive jewelry & clothing & draw potassium lab - K+ lab BECAUSE they could be susceptible to hyperkalemia due to the release of K in the damaged cells - Educate pts to avoid caffeine, alcohol, & tobacco. - No ambulation if the lower extremities are involved - **Additional measured:** whirlpool bath, escharotomy, and fasciotomy to tx compartment syndrome **Environmental Emergencies → Hypothermia, pg. 5781** - **Core temperature is 95 degrees or less as a result of exposure to cold or an inability to maintain body temperature** - **If frostbite is present as well, hypothermia takes precedence** - **Trauma increases the risk for hypothermia in EVERYONE** - Causes: ETOH, medications (phenothiazines), medical conditions (hypothyroidism, spinal cord injury), fatigue, and sleep deprivation - Generalized hypothermia: serious problem, once the core temp reaches 90 F there is no more shivering, cardiac dysrhythmias - S/sx: shivering, **low BP** & HR (maybe not detectable), progressive mental deterioration. - BP and HR may be so low not detectable (unable to feel pulses or get BP) - May not be able to shiver - **Monitoring: CVP (central venous pressure), ABG, CMP (Bun, Cr, Glucose, and Electrolytes), ECG, UOP, and chest X-ray** - Management: remove wet clothing, slowly rewarm, continuous monitoring, and supportive care - Active internal rewarming methods: cardiopulmonary bypass, warm fluid administration, warmed humidified oxygen by vent, and warmed peritoneal lavage - Passive or active external rewarming: used for mild hypothermia, over-the-bed heaters, and forced-air warming blankets - May have to administered sodium bicarb to correct metabolic acidosis if necessary - May also insert an indwelling catheter to monitor UOP **Animal and Human Bites, pg 5784** - Animal & Human Bites: cat bites have increased risk for infection; the human mouth contains more bacteria than that of most other animals, so a high risk of bite-related infection exists - 80-90% are dog bites - Clean w/ mild soap & water, tetanus vaccine if needed (if the animal cannot be located and rabies vaccination is verified, rabies prophylaxis for the person bitten must be instituted). - Human bites are associated with rapes, sexual assaults, or other forms of battery - **Human bite on arm, what does RN do?** - Clean with soap and water + tetanus shot + antibiotics + TAKE PIC for legal purposes **Snake Bites, pg. 5785** - **KNOW Most commonly in daylight hours and early evening in the summer months** - **KNOW Most common site: upper extremities and result in envenomation (injection of a poisonous material)** - **S/sx (be familiar with these)**: **edema, ecchymosis, hemorrhagic bullae leading to necrosis at the site of envenomation.** - **Other s/s: lymph node tenderness, N/V, numbness, and metallic taste in the mouth** - Snake bites can affect neurological status, cardiovascular and resp systems - Management - Remove constrictive items (ex: rings), provide warmth, cleanse the wound, light sterile dressing, below heart level - Tetanus and analgesia should be given if necessary - Labs: CBC, UA, and coagulation studies - **KNOW Measure the circumference of extremity** - **Need to remeasure every 30-60 mins for 48 hours to monitor for compartment syndrome** - **KNOW Contraindications: corticosteroids in the first 6 to 8 hours after bite b/c they may depress antibody production and hind the action of antivenin** - **Tx: antivenom is an immunoglobulin that can disable the toxin, most effective within 4 hours and NO greater than 12 hours after the snakebite** - Meds: CroFab or FabAV - Education on Serum Sickness: - **S/sx of serum sickness:** Fever, arthralgias, pruritus, lymphadenopathy, and proteinuria - Premedicate w/ IV Benadryl and Cimetidine to prevent serum sickness (not in book) **Poisoning pg. 5789:** - Inhale or ingest = Medical emergency - If ingested, they'll experience oral pain, vomiting, \[**write down from recording**\] - **Priorities: Remove or inactivate \[limit exposure\]** - Control of the airway, ventilation, and O2 is essential - Antidote administration if possible - Supportive care to decrease damage to organs - Treat to quickly eliminate absorbed poison - Management of Ingested Poison - Corrosive poisons - Alkaline/acidosis agents: damage mucus membranes - **KNOW Ex of alkaline agents → lye, drain cleaners, toilet bowl cleaners, bleach, non phosphate detergents, oven cleaners, and button batteries (batteries used to power watches, calculators, hearing aids, or cameras)** - **KNOW Ex of acidotic agents: toilet bowl cleaners, pool cleaners, metal cleaners, rust removers, and battery acid.** - Health history/incident history - Management: **ABCs, neuro status, renal function, shock, VS, EKG, insertion of indwelling catheter** - Remove or decrease absorption - **Corrosive agent → dilute with milk or water** - If swallowed something that is corrosive, **do not try to make them throw up** - Will burn going down & up - **Syrup of ipecac is no longer used** - **Never used due to the risk of Aspiration and should NEVER be used with with corrosive poisoning** - Gastric lavage for the patient who is obtunded is only usefully within 1 hour of ingestion - Activated charcoal administration if the poison is one that is absorbed by charcoal; given orally or by NG tube. It is effective in small intermittent doses to decrease vomiting. It absorbs commonly ingested positions - has risk of massive diarrhea, Sorbitol: sugar alcohol; active ingredient in activated charcoal. Prevents ?? - Cathartics are rarely indicated b/c they can result in severe electrolyte imbalances, diarrhea, and hypovolemia - If unknown, call local poison control center - **KNOW Monitor: VS, fluid & electrolyte status, CVP ?? \[listen under "syrup" slide\]** **Carbon Monoxide Poisoning, pg. 5791** - MOA: Binds to heme on the hemoglobin affecting the amount of oxygen molecules binding resulting in asphyxiation - Causes: industrial or household incident or attempted suicide - Psych consult for suicide attempt, health department for accident - CNS symptoms predominate: may appear intoxicated, **HA**, muscular weakness, palpitations, dizziness, confusion chest pain, blurred vision, nausea, SOB, flu like s/s (not in book) - Brain and Heart affected the most - Skin can be pink to cherry red OR pale and cyanotic, skin color alone is not a reliable sign - Long exposure: LOC, seizures, cardiac arrhythmias, and death (not in book) - Pulse Ox is not reliable b/c CO binds to hemoglobin w/ a higher affinity and molecules are saturated - Management: requires immediate treatment - Move the patient to fresh air, open all doors and windows, loosen all tight clothing, initiate CPR, wrap the patient in blankets, and keep the patient as quiet as possible - ABC's, CPR, 100% oxygen for short term to flush out CO as quickly as possible - Monitor continuously carboxyhemoglobin \< 5% - Drawn every hour, DC oxygen when less than 5 - Volume and Pressors (not in book) - Complications (not in book): seizures \[use dantrolene or benzos\], hypotension, arrhythmias, significant acidosis, **??** - If neuro s/s persists after resuscitation attempts, signifies permanent damage - s/s of neuro deficits: psychoses, spastic paralysis, ataxia, visual disturbances, and deterioration of mental status **Patients with Chemical Burns, pg. 5792** - Severity of chemical burn is determined by the MOA, penetrating strength and concentration, and the amount of exposure to the skin - Cause (not in book): fertilizer, **??** - Management - A wet chemical should be removed ASAP with copious amounts of water and If dry brush it off as gently as possible - The skin should be then flushed with constant stream of cool water as the pts clothing is removed - Prolonged lavage with generous amounts of tepid water is important - May also use a decontamination shower (deluge) - If in eyes flush eye from inner to outer canthus - Must wash hands with soap and water not hand sanitizer to not add alcohol; don PPE if required - Docoon (not in book) - Standard treatment: antimicrobial, tetanus prophylaxis, debridement, antidote - Plastic surgery is possible for further wound management - Recheck damaged area 24-72 hour and then 1 week later **Food Poisoning, pg. 5793** - **Chart 67-7, pg. 5793, do we need to know this?** - The key to tx is determining the source and type of food poisoning - Assessment: ABCs; Ask about onset, what was eaten, if anyone else is sick, v/d, fever. - **KNOW Respiratory paralysis if botulism exposure (yeah so where do we think this is?)** - **Botulism is a serious form of food poisoning that requires continual surveillance.** - Monitor: LOC, VS, resp status, F/E, GI losses, lethargy, tachycardia, fever, oliguria, anuria, delirium, & hypotension - Management: antiemetics **(Ondanzetron, Promethazine),** clear liquids once controlled for 12-24 hours before advancing diet, pt is encouraged to take sips of tea, carbonated drinks, or tap water