88884720-lesson-plan-emergency-nursing.docx

7/26/2019 88884720-Lesson-Plan-Emergency-Nursing.docx

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INTRODUCTION

Most patients with life-threatening or potentially life-threatening

problems arrive at the hospital through the emergency department

(ED). Many more patients report to the ED for less urgent conditions.

Emergency nurses care for patients of all ages and with a variety of

problems. However, some EDs specialie in certain patient populations

or conditions, such as pediatric ED or trauma ED.

Emergency management of patients with various medical, surgical,

and traumatic emergencies is presented throughout this boo!. "ables

that highlight emergency management of specific problems

HISTORY OF EMERGENCY NURSING

Emergency nursing was officially recognied as a specialty in #$%&.

"he national association representing these nurses ' the Emergency

urses *ssociation (E*+. +ts current membership comprises more

than ,&&& nurses who have chosen this area of professional nursing.

"he E* is recognied internationally and by #$$$ had approimately

/&& members from 0 different countries. Emergency nurses

throughout the world have realied both their similarities and

differences through use of the 1orld 1ide 1eb and increasing

international globaliation."he ED of the future is being formulated

today. ot only is technology changing, but the day-to-day processes


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that support the ED infrastructure are being challenged and

redesigned. "hese include concepts such as incorporating multiple

triage stations and bedside or bac!-end client registration2 using

computeried protocols, guidelines, and electronic medical records2

integrating nontraditional health care modalities2 initiating wireless

communication technology2 and creating 3virtual4 EDs.+n addition to the provision of direct client care, other multifaceted roles

eist within emergency nursing. "he emergency nurse is involved in

the initial triaging of clients according to illness severity, may perform

as a mobile intensive care nurse (M+5) by directing pre-hospital care

personnel via telecommunication, and fre6uently provides client care in

the pre-hospital environment. 5ommunity clinics use ED nurses, and

many emergency nurses have become active in in7ury prevention

programs at both national and local levels. *dvanced practice roles

such as clinical nurse specialists and nurse practitioners are integrated

into many EDs throughout the 8nited tates. urses in these

advanced practice roles often have a master9s degree level of

education or higher in addition to specialty certification.

SCOPE OF EMERGENCY NURSING

"he emergency nurse has had specialied education, training,

and eperience to gain epertise in assessing and identifying

patients9 health care problems in crisis situations.


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+n addition, the emergency nurse establishes priorities,

monitors and continuously assesses acutely ill and in7ured

patients, supports and attends to families, supervises allied

health personnel, and teaches patients and families within a

time-limited, high-pressured care environment.

ursing interventions are accomplished interdependently, in

consultation with or under the direction of a licensed physician

or nurse practitioner. "he strengths of nursing and medicine are

complementary in an emergency situation. *ppropriate nursing

and medical interventions are anticipated based on assessment

data.

"he emergency health care staff members wor! as a team in

performing the highly technical, hands-on s!ills re6uired to care

for patients in an emergency situation.

"he nursing process provides a logical framewor! for problem

solving in this environment. :atients in the ED have a wide

variety of actual or potential problems, and their condition may

change constantly. "herefore, nursing assessment must be

continuous, and nursing diagnoses change with the patient9s

condition. *lthough a patient may have several diagnoses at a

given time, the focus is on the most life-threatening ones2 often,

both independent and interdependent nursing interventions are

re6uired.

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LEGAL AND ETHICAL ISSUES IN EMERGENCY NURSING

A. LEGAL ISSUES

1. FEDERAL ISSUE

a. :ast federal legislation has mandated that any clientwho presents to an ED see!ing treatment must be

rendered aid regardless of financial ability to pay for

services. ince the mid-#$;&s, additional specific

legislation has been enacted re6uiring ED personnel

to stabilie the condemn of any client considered

medically unstable before transfer to another health

care facilityudget

?econciliation *ct (5=>?*) of #$; -and the

=mnibus >udget ?econciliation *ct (=>?*) of #$$&.

"his stabiliation mtist occur regardless of the

client9s financial ability to pay for services. ED

personnel who transfer clients to another institution

without first providing this initial stabiliation can

incur substantial fines and penalties, as can the

hospital administration.

b. 5lients have continued to see! health care servicesin the ED, even with the proliferation of managed

health care plans and gate!eeping policies. "he

financial integrity of the ED has been challenged

over the years due to the legal obligations of the ED

to provide service.


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c. ?etrospectively, financial reimbursement for

rendered services has been denied to EDs from

managed health care plans following a

determination that the client9s problem did not

constitute a true emergencyd. *dditional legislation was enacted (Emergency

Medical "reatment and *ctive 'abor *ct EM"*'* in

#$;;, #$;$, #$$&, and #$$/) re6uiring that a

medical screening eamination be performed on all

ED clients before solicitation of information about

ability to pay.0 "his medical screening eamination

must be inclusive enough to determine whether the

client is eperiencing an emergency medical

condition re6uiring treatment or, in the case of apregnant woman, is eperiencing labor contractions.

*n emergency medical condition includes drug

abuse, hemodynamic instability, psychiatric illness,

intoication, severe pan, and labor.e. +f a client has an emergency medical condition,

stabiliation must be rendered. tabiliation is

interpreted to mean that deterioration of the client is

unli!ely during possible transfer or discharge of the

client. 5ontinued interpretations of this act have

epanded the facilities that come under EM"*'*.

"hese include not only EDs. but also hospital owned

urgent care centers, anywhere unscheduled clients

appear for medical care, and off site locations that


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are within a &-yard one of a main hospital that is

covered under the & outpatient prospective

payment system. @iolations of this legislation can

again result in fines and penalties.

2. CONSENT TO TREAT

a. Most adult clients see!ing treatment in the ED givevoluntary consent to the standard and usual

treatment performed in this setting. +n some

instances, however, a client is deemed unable to

give consent for treatment. "his inability may be due

to the critical nature of the client9s illness or in7ury or

to other conditions, such as an altered level of

consciousness. +n these instances, emergency care

may be rendered to the client under the implied

emergency doctrine. "his doctrine assumes that the

client would consent to treatment to prevent death or

disability if the client were so able.b. 5hildren younger than the age of legal ma7ority must

have the consent of their parent or legal guardian for

medical care to be rendered. Eceptions include (#)

emancipated minors, () minors see!ing treatment

for communicable diseases, including seuallytransmitted diseases, in7uries from abuse, and

alcohol or drug rehabilitation, and (0) minor-aged

females re6uesting treatment for pregnancy or

pregnancy-related concerns. ome states also allow

the adult caregiver with whom the child resides to


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give treatment authoriation even though that

caregiver may not be the parent.c. "he issue of informed consent in the ED is the same

as in any other health care setting. *dult clients must

he informed about the necessity of re6uired

treatments, epected outcomes, and potential

complications. 5lients must also be mentally

competent and understand the information being

eplained. *s in any other setting, a mentally

competent adult client always maintains the right to

refuse treatment or withdraw previously given

consent.

3. RESTRAINTSa. ?estraining a client while he or she is in the ED may

at times be necessary. "he need for restraints

usually arises because the client is becoming

agitated or potentially violent. Hard leather or

chemical restraints are used in the ED if the client is

in danger of in7uring self or others and when

nonphysical methods of controlling the client are not

viable.b. ?estraints may not he used to control a client solely

for convenience or because of staffing issues.c. 1hen restraints are re6uired, departmental and

hospital guidelines that are in compliance with Aoint

5ommission and the 5enters for Medicare B

Medicaid ervices must he followed.d. * physician9s order for applying restraint as well as


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the client9s behavior mandating the use of restraints

most be documented.e. "he client must be periodically reevaluated both for

the continued need or restraints and the integrity of

distal circulation, motor movement, and sensory

level of the restrained etremities.

f. "he findings must be documented. =ffering water to

the client and providing opportunities to urinate or

relieve other body needs are re6uired, as is

documentation of this nursing care.g. o client may be !ept restraints against his or her

will unless the client9s behavior indicates the

eistence of safety issues.h. >ehavior modification techni6ues used in an attempt

to release the client from restraints must also be

documented. "he ED staff must receive appropriate

education pertaining to dealing with clients re6uiring

physical restraint.i. 5lients in the ED who have psychological conditions

that render them a danger to themselves or to

others, or who are unable to provide food or shelter

for themselves, can be placed and held on a legal

psychiatric restraining order. "H+s order mandates

that such clients be placed in a loc!ed psychiatric

facility for their protection for a maimum of %

hours. 1ithin that %-hour period, the client must be

evaluated by a psychiatrist to determine whether the

legal hold needs to be etended or whether the


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client can be released.

4. MANDATORY REPORTINGa. Every state has mandatory reporting regulations that

affect emergency nurses. +ncidents and conditions

may need to be reported to federal, state, or local

authorities or to the Department of :ublic Health,Department of Motor @ehicles, coroner9s offices, or

animal control agencies.b. "he types of incidents re6uiring reporting are

suspected child, seual, domestic, and elder abuse2

assaults2 motor vehicle crashes2 communicable

diseases such as hepatitis, seually transmitted

diseases, chic!en po, measles, mumps, meningitis,

tuberculosis, and food poisoning2 first time or

recurrent seiure activity2 death2 and animal bites.c. Every ED has written policies regarding these

mandatory reports.

5. EVIDENCE COLLECTION AND PRESERVATIONa. ?ecognition of unusual circumstances surrounding a

client9s in7ury or death is an important aspect of ED

nursing because of the associated legal implications.

ot only must tile legal authorities be notified, but

also, in many instances, the ED nurse may be

re6uired to collect and preserve evidence ta!en from

the client. "his evidence can include bullets,

weapons, clothing, and body fluid specimens.b. *ll collected evidence must be identified by the

client9s name, hospital identification number, date


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and time of evidence collection, type of evidence

and source e.g. venipuncture, hematoma, aspiration

vomitus, swab), and the initials or signature of the

person collecting the evidence. =nce the evidence

has been collected, its preservation and the

maintenance of the 3chain of custody4 are etremelyimportant.

. VIOLENCEa. @iolence directed against ED personnel has become

an issue of concern throughout the late #$$&s and


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into the #st century. "he environment inherent in

the ED, the emotional circumstances often

surrounding the illness or in7ury that affect both

clients and family members, and the increasingly

violent trends all play a role in this phenomenon.b. *dministrative changes have been made in some

EDs to enhance both public and health care wor!er

safety. "hese measures have included the

installation of items such as metal detectors, 3panic

buttons,4 bullet-proof glass, and loc!- down doors at

public entrances2 increasing the visibility of security

guards2 using patrol guard dogs2 and instituting

visitor control policies.c. 5hanging the perception of the ED from one of fear

and isolation for both clients and family members is

also occurring.d. +nstituting family centered practices that recognie

tile importance of family participation and addressing

the emotional needs of clients and families is a trend

in ED management.Collowing are areas to address

?ecogniing potentially violent clients and

situations

+dentifying verbally and physically abusive

signs from clients, family members, or friends

8nderstanding the importance of instinct or

gut , reactions

8sing simple communication strategies to

defuse potentially problematic situations


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?e6uiring clients to completely undress

before physical eamination

Minimiing the presence of 3potential

weapons4 in client care areas such as

scalpels, needles, ecess tubing attached to

oygen flow meters, scissors, stethoscopes

worn around the nec!, and personal 7ewelry.

?estraining clients, when necessary, using a

team approach.

*voiding becoming a hostage in a volatile

situation

Having safety committee trac! all reported

assaults on clients and employees

Ensuring =ccupational afety and Health

*dministration violence guidelines arefollowed

Encouraging employees to report both verbal

and physical assaults.

!. ETHICAL ISSUES

1. UNE"PECTED DEATHa. 1hen death occurs in the ED setting, it is usually

sudden and unepected, even if the client has had aprolonged illness. + hr unepected nature of the

death, or impending death, can present ethical

dilemmas for both the family survivors and the ED

personnel.;% =ne such issue deals with the length

to which resuscitation is performed. "his is usually a


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physician9s decision2 however, family members may

at times have input. *llowing family members or

significant others to be present during client

resuscitation is becoming more common. "his

practice is not necessarily disruptive to the

resuscitation process, and it can be of comfort to thesurvivors and the involved ED personnel.

b. 1hen death does occur, the ED nurse and the ED

physician have important roles in informing the

familyi. +nform the family of the client9s death, and

refer to the deceased client by name.ii. :rovide the family with an eplanation of the

course of events related to the death2 use

simple eplanations.iii. =ffer the family an opportunity to view the

body. +f a child has died, allow the parent to

hold the child. :roviding the parent with a

loc! of the child9s hair may be comforting.iv. Help the family to focus on decisions

re6uiring immediate attention such as ta!ing

possession of the deceased person9s

valuables, arranging postmortem

eamination if desired or re6uired, identifying

possible organ or tissue donation, and

selecting a funeral home.v. +nform family members when they can leave

the ED setting.vi. :rovide community agency referral as


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needed.

2. ORGAN AND TISSUE DONATION+ssues related to potential organ or tissue donation

often arise in the ED setting. =nce a potential donor

is identified, the surviving family members need to

be approached. * team approach involving aphysician, a nurse, arid possibly an organ

procurement coordinator is optimal. 8tmost dignity

and professionalism must be maintained. 1hatever

decision the family ma!es regarding organ or tissue

donation, that decision must be supported by health

5are personnel.

3. CHILDA!ONDONMENT

tates are beginning to pass child abandonment laws in

response to the number of newborn infants being

abandoned following birth. +n general, the law allows

mothers to bring their newborn child to the ED and abandon

the child in the care of the ED personnel. "he mother bears

no criminal responsibility. 'ocal Departments of ocial

ervices are then contacted so the child can be placed in

their custody.

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PRINCIPLES OF EMERGENCY CARE


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A. TRIAGE"riage, a Crench word meaning 3to sort,4 refers to the process

of rapidly determining patient acuity. +t is one of the most

important assessment s!ills needed by the emergency nurse.#

"he triage process is based on the premise that patients who

have a threat to life, vision, or limb should be treated before

other patients. * triage cistern identifies and categories

patients so that the most critical are treated first.*fter the emergency nurse completes the initial assessment to

determine the presence of actual or potential threats to life,

appropriate interventions are initiated for the patient9s condition.

* history is obtained simultaneously with the assessment. *

systematic approach to the initial patient assessment

decreases the time re6uired to identify potential threats and

minimies the ris! of overloo!ing a life-threatening condition.

"wo systematic approaches, a primary survey and a secondary

survey, were initially developed for use with the trauma patient,

but these can be easily applied to assessment of any

emergency patient.

!. PRIMARY SURVEY"he primary survey focuses on airway, breathing, circulation,

and disability and serves to identify life-threatening conditions

so that appropriate interventions can be initiated. 'ife-

threatening conditions related to airway, breathing, circulation,

and disability may be identified at any point during the primary


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survey. 1hen this occurs, interventions are started immediately

and before proceeding to the net step of the survey.

A #A$%&a' &$() Ce%*$ca+ S,$-e S(ab$+$a($/- a-d0/%

I/b$+$a($/-.#. early all immediate trauma deaths occur because of

airway obstruction. aliva, bloody secretions, vomitus,laryngeal trauma, dentures, facial trauma, fractures, and the

tongue can obstruct the airway. :atients at ris! for airway

compromise include those who have seiures, near-

drowning, anaphylais, foreign body obstruction, or

cardiopulmonary arrest. +f an airway is not maintained,

obstruction of airflow occurs and hypoia, acidosis, and

death may result.. :rimary signs and symptoms in a patient with a

compromised airway include dyspnea, inability to vocalie,

presence of foreign body in the airway, and trauma to the

face or nec!. *irway maintenance should progress rapidly

from the least to the most invasive method.

0. "reatment includes opening the airway using the 7aw-thrust

maneuver (avoiding hyperetension of the nec!), suctioning

and or removal of foreign body, insertion of a

nasopharyngeal or an oropharyngeal airway (will cause

gagging if patient is conscious), and endotracheal

intubation. if unable to intubate because of airway

obstruction, an emergency cricothyroidotomy or

tracheotomy should be performed. :atients should be

ventilated with #&& oygen using a bag valve mas! (>@M)


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device before intubation or cricothyroidotomy./. ?apid se6uence intubation is the preferred procedure for

securing an unprotected airway in the ED. +t involves the

use of sedation (e.g. etomidate) and paralysis (eg..

succinylcholine) to facilitate intubation while minimiing the

ris! of aspiration and airway trauma.

. *ny patient with face, head, or nec! trauma and or on

significant upper torso in7uries should always be suspected

of cervical spine a neutral position) and or immobilied

during assessment of the airway. *t the scene of the in7ury,

the cervical spine is immobilied with a rigid cervical collar

or a cervical immobiliation device (5ED) (also !nown as

Fhead bloc!s4). "owel rolls are taped to a bac!board on

either side of the head. Cinally, the patient9s forehead is

secured to the bac!board. andbags should not be used

because the weight of the bags could move the head if the

patient must be log-rolled.

! #!%ea()$-.

#. *de6uate airflow through the upper airway does not ensure

ade6uate ventilation.. >reathing alterations are caused by many conditions,

including fractured ribs, pneumothora, penetrating in7ury,

allergic reactions, pulmonary emboli, and asthma attac!s.0. :atients with these conditions may eperience a variety of

signs and symptoms, including dyspnea (e.g., pulmonary

emboli), paradoic or asymmetric chest wall movement

(e.g. flail chest), decreased or absent breath sounds on the


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affected side (e.g. pneumothora) visible wound to chest

wall (e.g., penetrating in7ury), cyanosis (e.g., asthma),

tachycardia, and hypotension./. Every critically in7ured or ill patient has an increased

metabolic and oygen demand and should have

supplemental oygen.

. High flow oygen (#&&) via a non-re-breather mas!

should be administered and the patient9s response

monitored. 'ife-threatening conditions, such as tension

pneumothora and flail chest, can severely compromise

ventilation, +nterventions in these situations include >@M

ventilation with #&& oygen, intubation, and treatment of

the underlying cause.

C # C$%c+a($/-.

#. *n effective circulatory system includes the heart, intact

blood vessels, and ade6uate blood volume.. 8ncontrolled internal andGor eternal bleeding places a

person at ris! for hemorrhagic shoc!.0. * central pulse (e.g., carotid) should be chec!ed because

peripheral pulses may be absent as a result of direct in7ury

or vasoconstriction./. +f a pulse is palpated, the 6uality and rate of the pulse are

assessed.. !in should be assessed for color, temperature, and

moisture.. *ltered mental status is the most significant signs of shoc!.%. 5are must be ta!en when evaluating capillary refill in cold


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environments because cold delays refill.. +ntravenous (+@) lines are inserted into veins in the upper

etremities unless contraindicated, such as in a massive

fracture or an in7ury that affects limb circulation.%. "wo large-bore (#/- to #-gauge) +@ catheters should be

inserted and aggressive fluid resuscitation initiated using

normal saline or ?inger9s lactate solution.;. Direct pressure with a sterile dressing should be applied to

obvious bleeding sites. >lood samples are obtained for

typing to determine *>= and ?h group.$. "ype specific pac!ed red blood cells should be

administered if needed. +n an emergency (life-threatening)

situation, uncrossmatched blood may be given if immediate

transfusion is warranted.#&. "he use of the pneumatic antishoc! garment (:*I) is a

temporary strategy that may be considered for pelvic

fracture bleeding with hypotension./ "he :*I is a three-

chambered suit that is applied to the patient9s legs and

abdomen and is inflated with a foot pump. :hysiologically,

the :*I increases peripheral vascular resistance in the

patient9s lower etremities, thus elevating blood sure, and

wor!s to control pelvic fracture bleeding.##. 5are must ta!en when deflating the garment. ?apid

deflation can result in a severe drop in peripheral vascular

resistance and blood pressurealternative devices to the

:*I include pelvic splints and belts.

D # D$ab$+$('.

1. * brief neurologic eamination completes the primary


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survey. "he degree of disability is measured by the patients

level of consciousness. Determining the patient9s response

verbal andGor painful stimuli is one approach to assessing

level consciousness. * simple mnemonic to remember is

*@:8 * J alert, @ J responsive to voice, : J responsive to

pain, and 8 < unresponsive.2. +n addition, the Ilasgow 5oma cale is used to assess the

arousal aspect of the patent9s consciousness.3. Cinally, the pupils should be also assessed for sie, shape,

response to light, and e6uality.

C. SECONDARY SURVEY*fter each step of the primary survey is addressed and any

lifesaving interventions are initiated, the secondary survey

begins."he secondary survey is a brief, systematic process that is

aimed at identifying all in7uries.

E#E,/%e0E-*$%/-e-(a+ C/-(%/+*ll trauma patients should have their clothes removed so

that a thorough physical assessment can be performed.

=nce the patient is eposed, it is important to limit heat loss

and prevent hypothermia by using warming blan!ets,

overhead warmers, and warmed +@ fluids.

F#F++ Se( /6 V$(a+ S$-0F$*e I-(e%*e-($/-0Fac$+$(a(e

Fa$+' P%ee-ce.#. * complete set of vital signs, including blood pressure, heart

rate, respiratory rate, and temperature, should be obtained

after the patient is eposed.


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. >lood pressure should be obtained in both arms if the

patient has sustained or is suspected of having sustained

chest trauma, or if the blond pressure is abnormally high or

low.0. *t this point, it must be determined whether to proceed with

the secondary survey or to perform additional interventions.

"he availability of other team members often influences this

decision. Cor patients who have sustained significant

trauma andGor have re6uired lifesaving interventions during

the primary survey, the following five interventions should

be performed at this timea. "he patient should he monitored h

electrocardiogram (E5I) for heart rate and rhythm.b. "he pulse oymetry should ho initiated and oygen

saturation (p&) monitored.c. *n indwelling catheter should be inserted to monitor

urine output and to chec! for hematuria, *n

indwelling catheter should not be inserted if a

urethral tear is suspected. :atients with pelvic

in7uries, with blood at the meatus, or who are unable

to void, and men with a high-riding prostate gland on

digital rectal eamination, are at ris! for a urethral

tear or transection. * retrograde urethrogram shouldbe obtained before a catheter is inserted.

d. *n =rogastric or a nasogastric tube should be

inserted to provide gastric decompression and

emptying to reduce the ris! of aspiration and to test

the contents for blood. * nasogastric tube should not


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be placed in the nares of a patient suspected of

having facial fractures or a basilar s!ull fracture

because the tube could enter the brain through the

cribriform plate2 rather, it should be placed orally.e. 'aboratory studies for typing and crossmatching,

hematocrit, hemoglobin, blood urea nitrogen,

creatinine, blood alcohol, toicology screening,

arterial blood gas (*>Is), electrolytes, coagulation

profile, liver enymes, cardiac enymes, and

pregnancy should be facilitated.

Cacilitating 6a$+' ,%ee-ce(C:) completes this

step of the secondary survey. ?esearch supports the

benefits of C: during resuscitation and invasive

procedures to patients, families, and staff. :atients

reported that having family members present comforted

them, served as an advocate for them, and helped to

remind the health care team of their 3personhood.

Camily members who wished to be present during

invasive procedures and resuscitation viewed

themselves as active participants in the care process.

"hey also believed that they provided comfort to thepatient and that it was their right to be with the patient.

taff nurses reported that family members who

participated in C: functioned as 3patient helpers4 (e.g.

providing support) and 3staff helpers4 (e.g., acting as a

translator) and reinforced that C: helped to convey the


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sense of the patient9s personhood. hould a family

member re6uest C: during resuscitation or invasive

procedures, it is essential that a member of the team he

designated to eplain care delivered and be available to

answer 6uestions.

G # G$*e C/6/%( Mea%e.#. :rovision of comfort measures is of paramount importance

when caring for patients in the ED. +t has been reported that

pain is the primary complaint of all patients who come to the

ED.. Many EDs have developed nurse-initiated pain

management protocols to treat pain early, beginning at

triage. :ain management strategies should include a

combination of pharmacologic (e.g. nonsteroidal anti-

inflammatory drugs, +@ opioids) and non-pharmacologic

(e.g., imagery, distraction) measures.0. Emergency nurses play a pivotal role in ongoing pain

management because of their fre6uent contact with

patients. Ieneral comfort measures such as verbal

reassurance, listening, reducing stimuli (e.g., dimming

lights), and developing a trusting relationship with the

patient and family should he provided to all patients in the

ED.


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H # H$(/%' a-d )ead7(/7(/e aee-(

1. H$(/%' )/+d $-c+de 6/++/&$- 8e($/-a. 1hat is the chief complaintKb. 1hat caused the patient to see! attentionKc. 1hat are the patient sub7ective complaintsKd. 1hat is the patient9s description of pain (e.g..

location, duration. 6uality, character)K

e. 1hat are witnesses9 (if any) descriptions of the

patient9s hehaFior since the onsetKf. 1hat is the patient9s health historyK

"he mnemonic *M:'E is a memory aid that

prompts the nurse to as! about the following* J *llergiesM J Medication history: J :ast health history (e.g., preeisting medical

andGor psychiatric conditions, previous

hospitaliationsGsurgeries, smo!ing history, recent

use of drugsGalcohol, tetanus immuniation, last

menstrual period, baseline mental status).'J 'ast meal

EJ EventsGenvironment preceding illness or in7ury

2. Head9 Nec:9 a-d Face

"he patient should be assessed for general

appearance, s!in color, and temperature.

"he eyes should be evaluated for etraocular

movements. * discon7ugate gae is an indication of neurologic

damage.

>attle9s sign, or bruising directly behind the ear(s),

may indicate a fracture of the base of the posterior

portion of the s!ull.

3?accoon eyes,4 or periorbital ecchymosis, is usually


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an indication of a fracture of the base of the frontal

portion of the s!ull.

"he tympanic membranes and eternal canal are

chec!ed for blood and cerebrospinal fluid.

5lear drainage from the ear or nose should not be

bloc!ed.

"he airway is assessed for foreign bodies, bleeding,edema, and loose or missing teeth.

*ssess for difficulty swallowing, movement.

"he trachea is palpated and visualied to determine

whether it is midline. * Fdeviated trachea may signal,

a life-threatening tension pneumothora.

ubcutaneous emphysema may indicate

laryngotracheal disruption

* stiff or painful nec! area may signify a fracture of

one or more cervical vertebrae. "he cervical spine must be protected using a rigid

collar and supine positioning. :atients must be

logrolled while maintaining cervical spine

immobiliation when movement is necessary.

3. C)e(.

"he chest is eamined for paradoic chest

movements and large suc!ing chest wounds.

"he sternum, clavicles, and ribs are palpated for

deformity and point tenderness.

"he chest is assessed for pain on palpation,

respiratory distress, decreased breath sounds,

distant heart sounds, and distended nec! veins

+n addition to tension pneumothora and open


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pneumothora, the patient should be evaluated for

rib fractures, pulmonary contusion, blunt cardiac

in7ury, and haemothora.

* #-lead E5I should be obtained, particularly on a

patient with !nown or suspected heart disease.

"he E5I should be done to detect dysarrhythmias

and evidence of myocardial ischemia or infarction.

4. Abd/e- a-d F+a-:.

"he abdomen and flan!s are more difficult to

assess. Cre6uent evaluation for subtle changes in

the abdominal eamination is essential. Motor

vehicle collisions and assaults can cause blunt

trauma. :enetrating trauma tends to in7ure specific,

solid organs (e.g., spleen).

Decreased bowel sounds may indicate a temporary

paralytic ileus.

>owel sounds in the chest may indicate a

diaphragmatic rupture.

"he abdomen is percussed for distention e.g.

tympany (ecessive air), dullness Lecessive fluid)

and palpated for peritoneal irritation.

+ntra-abdominal hemorrhage is suspected, a

focused abdominal sonography for trauma (C*")

to determine the presence of blood in the peritoneal

space (hemoperitoneum) is preferred. "his

procedure is noninvasive and can be performed

6uic!ly at the bedside.

*n alternative, a diagnostic peritoneal lavage, may


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be considered. >efore this procedure, a gastric tube

and a bladder catheter must be inserted to

decompress these organs and reduce the possibility

of perforation.5. Pe+*$ a-d Pe%$-e.

"he pelvis is gently palpated, not roc!ed. +f pain is

elicited, it may indicate a pelvic fracture. "he genitalia are inspected for bleeding and obvious

in7uries.

* rectal eamination is performed to chec! for blood,

a high-riding prostate gland, and loss of sphincter

tone.

*ssess for bladder distention, hematuria, dysuria, or

the inability to void.

. E(%e$($e. "he upper and lower etremities are assessed for

point tenderness, crepitus, and deformities.

+n7ured etremities are splinted above and below the

in7ury to decrease further soft tissue in7ury and pain.

Irossly deformed, pulseless etremities should be

realigned and splinted.

:ulses are chec!ed before and after movement or

splinting of an etremity.

* pulseless etremity is a time-critical vascular ororthopedic emergency.

Etremities are also assessed for compartment

syndrome. "his occurs as pressure and swelling

increase inside a section of an etremity (e.g.,

anterior compartment of lower leg), compromising


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the viability of the etremity muscles, nerves, and

arteries.

I # I-,ec( ()e ,/(e%$/% %6ace

+nspect the :osterior urfaces. "he trauma patient should

always be logrolled (while maintaining cervical spine

immobiliation) to inspect the patient9s posterior surfaces. "he

bac! is inspected for ecehymoses, abrasions, puncture

wounds. cuts, and obvious deformities. "he entire spine is

palpated for misalignment, pain, deformity.

INTERVENTION AND EVALUATION

=nce do secondary survey is complete, all findings arerecorded. *ll patients should >e evaluated to determine their

need for tetanus prophylais. +nformation about the patient9s

past vaccination history and the condition of any wounds is

needed in order to ma!e an appropriate decision.

?egardless of the patient9s chief complaint, ongoing patient

monitoring and evaluation of interventions are critical in an

emergency situation.

"he nurse is responsible for providing appropriate interventions

and assessing the patient9s response. "he evaluation of airway

patency and the effectiveness of breathing will always assume

highest priority. "he nurse will monitor & saturation and *>Is

to help determine the patient9s progress in these areas. 'evel of

consciousness, vital signs, 6uality of peripheral pulses, urine


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output, and s!in temperature, color, and moisture provide !ey

information about circulation and perfusion and are also closely

monitored.

Depending on the patient9s in7uries andGor illness, the patient

may be (+) transported for diagnostic tests such as N-ray or 5"

scan () admitted to a general unit, telemetry, or an intensive

care unit2 or (0) transferred to another facility. "he emergency

nurse is responsible for monitoring the critically ill patient during

intrafacility and interfacility transport and notifying the team

should tile patient9s condition change from baseline. urses

accompanying patients on transports must be competent in

advanced life-support measures.

Dea() $- ()e Ee%e-c' De,a%(e-(8nfortunately, there are a number of emergency

patients who do not benefit from the s!ill, epertise, and

technology available in the ED. +t is important for the

emergency nurse to be able to deal with feelings about sudden

death so that the nurse can help families and significant others

begin the grieving process.

"he emergency nurse should recognie the importance

of certain hospital rituals in preparing the bereaved to grieve,

such as collecting the belongings, arranging for an autopsy,

viewing tile body, and ma!ing mortuary arrangements. "he

death must seem real so that the significant others can begin to

grieve and accept tile death. "he emergency nurse plays a


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significant role in providing comfort to tile surviving loved ones

after a death in the ED.

Many patients who die in tile ED could potentially be a

candidate for nonheart beating donation. 5ertain tissues and

ureiiis such as cornea, heart valves, s!in, bone, and !idneys

can be harvested from patients after death.

*pproaching families about donation after an

unepected death is distressing to both the staff and the family.

Cor many families, however, the act of donation may be the first

positive step in the grieving process. =rgan are available to

assist in the process of screening potential donors, counseling

donor families, obtaining informed consent, and harvesting

organs from patients who have died in the ED.


31/38

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Sa%'

"ill now we have seen about the definition, history, scope,

legal and ethical issues in emergency nursing, principles of

emergency management, emergency conditions and their

nursing management.

C/-c+$/-

* stitch in time saves nine, and it is better to be prepared

rather than un!nown. "rauma can be controlled but not all,

controllable can be prevented by appropriate human behavior.

During trauma help should be implanted as soon as possible to

avoid further casualities.

A$-e-(

solve the #& multiple choice 6uestions, #& mar!s


32/38

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no

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N

!I!LIOGRA$H%&

'. Lewis, Heitkemper & Dirksen (2000) Medical Surgical

Nursing Assessment and Management o !linical "ro#lem

($t%ed) Mos#, pg no' 22**.

2' +lack 'M' Hawk, 'H' (200) Medical Surgical Nursing

!linical Management or "ositi-e .utcomes' ($t% ed)

/lse-ier, pg no' 21'

(. +runner S' +', Suddart% D'S' %e Lippincott Manual o

Nursing practice '+'Lippincott' "%iladelp%ia, pg no' 3201

4

). 5nderstanding medical surgical nursing, 6 A Da-is *t%

edition, elsiei-er pu#lication pg' no' 21022'*.+++.ene.or,-issues.t/0
http://www.ene.org/issues.htmlhttp://www.ene.org/issues.html


33/38

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EVAL#ATIO

N

1. INEFFECTIVE AIR;AY CLEARANCE

* compromised or ineffective airway ma9 he due to

either complete or partial airway obstruction. 5ommon causes

of airway compromise include the presence of a foreign ob7ect

in the airway, airway edema, airway infection, facial or airway

in7ury, and tongue obstruction.

CLINICAL MANIFESTATIONS

*bsence of respirations

Drooling

stridor,

intercostal or substernal retractions

cyanosis, a mid agitation

* decreased level of 5onsciousness may lead to airway

compromise as a result of obstruction of the posterior

pharyn by the relaed tongue.

Ma-aee-t

Re/*e Ob(%c($/-.

+f an obstruction is present, the airway should be opened by a

chin lift or 7aw thrust maneuver. +f either of these maneuvers

opens the client9s airway, patency is maintained via the


34/38

insertion of a nasopharyngeal or oral airway device. +f these

maneuvers fail to relieve the obstruction, more aggressive

interventions must he instituted, such as

performing abdominal or chest thrusts if an aspirated

foreign ob7ect is the suspected cause

suctioning the oral cavity to remove secretions or visible

foreign ob7ects

+ntubating via the nasal or oral route 8sing a laryngeal mas! airway ('M*),

*ssisting with creating a surgical airway via a

cricothyroidotomy.

I-(ba(e

+n some cases, oral or nasal intubation may re6uire the use of

rapid-se6uence induction (?+) "his procedure is used in

awa!e clients who re6uire intubation either to maintain the

airway or as a mechanism to provide ade6uate ventilation. ?+

is most fre6uently used in clients who have sustained a heador spinal in7ury and in clients who are rapidly tiring from the

effort of maintaining respirations. ?bO involves

Establishing venous access

Hyperventilating the client with #&& oygen,

*dministering intravenous (+@) lidocaine + opG!g to blunt

any transient increase in intracranial pressure from the

actual intubation procedure

*dministering an +@ general barbiturate or anesthetic

medication such as thiopental 0 to mgG!g,

Ve%$6' Tbe P+acee-(

*fter the intubation procedure, the ED nurse is

immediately responsible for auscultation of the client9s

chest during assisted ventilation to confirm the presence

of e6ual bilateral breath sounds.

+f breath sounds are heard over the epigastric area, the


35/38

tracheal tube must be removed, the client

hyperventilated, and the procedure reattempted.

>reath sounds heard more prominently over the upper

right chest indicate that the tracheal tube has advanced

far into the right main bronchus. "he tube needso be

pulled-hac! and breath sounds reassessed.

=nce the presence of e6ual and bilateral breath sounds

is confirmed, the tube is secured in place and a chestfilm is obtained to document correct tube placement.

ecuring and maintaining a patent airway constitutes

the first priority in any ED client. =ther treatments

directed at the cause of airway compromise are then

instituted. "hese measures may include administration

of +@ medications if infection or local edema of the

airway is present.

I/b$+$e ()e S,$-e

+f the client with an actual or potential airway problem

has also sustained a traumatic in7ury, simultaneous stabiliation

of the client9s cervical, thoracic, and lumbar spine must be

instituted and maintained to prevent any further possible spinal

in7ury.

Manually stabiliing the client9s head and

cervical spine

*pplying a hard cervical collar around the client9s

nuchal area

:lacing the client on a long, rigid bac!board

ecuring the client to the bac!board

:lacing immobiliation devices, such as rolled

towels, at the side of the client9s head and nec!,

and

:lacing a strip of adhesive tape across the

client9s forehead and immobiliation devices and


36/38

then onto the bac!board.

2. INEFFFECTIVE !REATHING PATTERNHYPERVENTILATIONCLINICAL MANIFESTATIONS

Cast respiratory rate

umbness

"ingling sensation

5arpal or pedal spasm

*niety

MANAGEMENT

+nstruct patient to ta!e slow breath

+nstruct him to breath in paper bag and rebreath their

own carbon dioide

HYPOVENTILATION

C+$-$ca+ Ma-$6e(a$/-

?E:+?*"=?P ?*"E 'E than #Gmin

Decreased level of consciousness

:allor

5yanosis

Ma-aee-(

*dminister high flow oygen by bag valve mas!

3. IMPAIRED GAS E"CHANGE

*bnormal lung sound rhonchi, wheeing

:neumothora (diminished or absent breath sound in

affected side) *symmetrical hest movements (trauma or flail chest)

4. TRAUMATIC PNEUMOTHORA"

Cae


37/38

"rauma to chest

C+$-$ca+ a-$6e(a($/-

:enetrating in7ury or =pen wound on chest

:ain

Ma-aee-(

*dminister oygen at high flow via face mas!

*pply occlusive dressing on open chest wound +nsert #/-# gaue needle in anterior chest at nd

intercostals space in midclavicular line to drain the air.

:lace chest tube with collection bag or suction tube

5. FLA+L C+EST* flail chest involves serious rib fractures. +t occurs when two or

more ribs are fractured in two or more places on the same

chest wall side or when the sternum is detached from the ribs.

"he fractured segment has no connection with the remaining rib

cage. "his segment then moves in a direction opposite that of

the rest of the chest wall during the processes of inhalation andehalation so-called paradoical chest wall movement (Cigure

;/-$). ?espiratory distress is present, as are s!in pallor and

cyanosis. "reatment involves nasal or tracheal intubation and

mechanical ventilation with positive end-epiratorv pressure

(:EE:). :ulmonary contusions are commonly present in

con7unction with a flail chest, and within / to /;

Sr

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