Emergency

1. Emergency By: Diana Blum MSN Metropolitan Community College

2. Environment of Care • Rapid change • Noisy • Unpredictable

3. Demographic • Multiple specialties • Increasing visits to 123.8 million in 2011 • Avg age of patient is 35.7 yrs old • 75 + years old highest visit rate • Common reasons for healthcare seeking: • Chest pain • Abd pain • Headache • fever

4. Team Members • ER nurse • EMTs • Paramedics • Physcians • Ancillary members: admissions, radiology, etc. • Special teams: forensic nurse, psychiatric team

5. Client Safety • All patients have ID number and if unconscious they are named John or Jane Doe • If unconscious the nurse plays detective • Prevent falls and breakdown • Get med list if available • Always ask allergies if able • Look for medic alert bracelets, necklaces • Standard precaution always • Recognize volatile situations (plan escape route)

6. Priority Emergency Measures for All Patients • Make safety the first priority • Preplan to ensure security and a safe environment • Closely observe patient and family members in the event that they respond to stress with physical violence • Assess the patient and family for psychological function

7. Patient and family-focused interventions • Relieve anxiety and provide a sense of security • Allow family to stay with patient, if possible, to alleviate anxiety • Provide explanations and information • Provide additional interventions depending upon the stage of crisis

8. ER Nursing • 6 months to 1 year acute care/ICU training • Some ERs will hire new grads using intern program

9. Technical Skills • Multitasking • Assist with: • Wound closure • Foreign body removal • Central line insertion • Transvenous pacemaker insertion • Lumbar puncture • Pelvic exam • Chest tube insertion • Lavage • Fracture management http://www.youtube.com/watch?v=n5Zw4ZARvNg

10. Core Competencies

11. Knowledge of ER Care • Broad based • Multi disease process/insects/snakes/animals • Mandatory reporting for sexual assault, abuse • BLS, ACLS, PALS

12. Assessment • Rapid recognition of abnormal findings • Must be aware of comorbidites • Act Quickly

13. Communication • Complex barriers • Use professional language • Protect HIPPA related information

14. Triage • Means: to sort: ED triage differs from disaster triage in that patients who are the most critically ill receive the most resources, regardless of potential outcome • Across-the-room assessment • starts with visual contact, general appearance, work of breathing, skin color • Determine chief complaint 3. Focused assessment • (Subjective data) demographics, onset of symptoms, past medical history, LMP, current meds, allergies • (Objective data) inspection, palpation, auscultation, obtain vital signs

15. Basic Elements • Assign acuity level • Emergent: immediate threat to life or limb • CODE, Respiratory Failure, Chest pain, hemorrhage • Urgent: treat quickly but life no immediate threat present at this time • Pneumonia, abd pain, fractures • Non-Urgent: can wait for several hours if needed • Strains, sprains, toothaches, cold, some rashes

16. 5 Level Triage • Level 1- immediate life saving interventions, many resources • Level 2- high risk, many resources • Level 3- urgent, two or more resources, wait 30 min • Level 4- non-urgent one resource, wait up to 1 hour • Level 5-no resources, wait up to 2 hours

17. Examples • Level 1- CPR, intubation required • Level 2- chest pain, dyspnea, suicidal with plan or attempt, stroke, pregnant with active bleeding • Level 3-abdominal pain, closed fractures, dislocations • Level 4- sore throat, strains, sprains, URI, • Level 5- suture removal, medication refill, certain rashes

18. Resources • Labs IV fluids • XRAY Consults • EKG Simple procedure • CT/MRI Complex procedure • IV/IM medications

19. Primary Survey • A:Airway • patency, watch for tripod, stridor, inability to speak, rise and fall of chest • B: Breathing • rate and depth, breath sounds, chest expansion, skin color, spontaneous breathing • C: Circulation • heart rate, pulses, blood pressure, skin, cap refill D:DisabilityAlertness, Responsive toVoice, Responsive to pain, Unresponsiveness E:Exposure Remove clothing, keep pt warm

20. 2nd ary Survey • Identifies other injuries or medical issues that needs to be managed

21. Secondary Survey • Before beginning Secondary survey • Attach EKG leads, Pulse ox, C02 device to ETT, foley cath if not contraindicated, NG, radiographs -Full set of vital signs/Focused interventions FAST scan-focused assessment -Give comfort measures -History/Head to toe assessment Pre-hospital info AMPLE

22. Priorities of Care for the Patient With Multiple Trauma • Use a team approach • Determine the extent of injuries and establish priorities of treatment • Assume cervical spine injury-log roll protect spine • Assign highest priority to injuries interfering with vital physiologic function

24. Hemorrhage Control

25. Care of Client • Place client in hospital gown • Ensure privacy • Med administration as ordered • Assist with procedures • Reprioritize and reassess as needed

26. Disposition • Admitted or discharged is the question • What is the nurses role?

27. Case Management • Nurse case managers intervene when necessary to assist in making follow up and referral arrangements especially with elderly and homeless, and abused clients

28. Teaching • review D/C instructions • Reinforce safety (sealtbelt wearing) • Discuss home safety (detectors, fall prevention) • teach new procedures that will continue at home

29. Priority Setting • Triaging client care • Critical thinker • Go to Prioritization PPT