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A V AIDS BLACKBOARD

ACTIVITYEVALUATION

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 specialize 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 book. Tables

that highlight emergency management of specific problems

HISTORY OF EMERGENCY NURSING

Emergency nursing was officially recognized as a specialty in 1970.

The national association representing these nurses LS the Emergency

Nurses Association (ENAI. Its current membership comprises more

than 25,000 nurses who have chosen this area of professional nursing.

The ENA is recognized internationally and by 1999 had approximately

400 members from 35 different countries. Emergency nurses

throughout the world have realized both their similarities and

differences through use of the World Wide Web and increasing

international globalization. The ED of the future is being formulated

today. Not only is technology changing, but the day-to-day processes

that support the ED infrastructure are being challenged and

redesigned. These include concepts such as incorporating multiple

triage stations and bedside or back-end client registration; using

computerized protocols, guidelines, and electronic medical records;

integrating nontraditional health care modalities; initiating wireless

communication technology; and creating “virtual” EDs.

In addition to the provision of direct client care, other multifaceted roles

exist within emergency nursing. The emergency nurse is involved in

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

as a mobile intensive care nurse (MICN) by directing pre-hospital care

personnel via telecommunication, and frequently provides client care in

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

many emergency nurses have become active in injury prevention

programs at both national and local levels. Advanced practice roles

such as clinical nurse specialists and nurse practitioners are integrated

into many EDs throughout the United States. Nurses in these

advanced practice roles often have a master’s degree level of

education or higher in addition to specialty certification.

SCOPE OF EMERGENCY NURSING

The emergency nurse has had specialized education, training,

and experience to gain expertise in assessing and identifying

patients’ health care problems in crisis situations.

In addition, the emergency nurse establishes priorities,

monitors and continuously assesses acutely ill and injured

patients, supports and attends to families, supervises allied

health personnel, and teaches patients and families within a

time-limited, high-pressured care environment.

Nursing interventions are accomplished interdependently, in

consultation with or under the direction of a licensed physician

or nurse practitioner. The strengths of nursing and medicine are

complementary in an emergency situation. Appropriate nursing

and medical interventions are anticipated based on assessment

data.

The emergency health care staff members work as a team in

performing the highly technical, hands-on skills required to care

for patients in an emergency situation.

The nursing process provides a logical framework for problem

solving in this environment. Patients in the ED have a wide

variety of actual or potential problems, and their condition may

change constantly. Therefore, nursing assessment must be

continuous, and nursing diagnoses change with the patient’s

condition. Although a patient may have several diagnoses at a

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

both independent and interdependent nursing interventions are

required.

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ACTIVITYEVALUATION

LEGAL AND ETHICAL ISSUES IN EMERGENCY NURSING

A. LEGAL ISSUES

1. FEDERAL ISSUE

a. Past federal legislation has mandated that any client

who presents to an ED seeking treatment must be

rendered aid regardless of financial ability to pay for

services. Since the mid-1980s, additional specific

legislation has been enacted requiring ED personnel

to stabilize the condemn of any client considered

medically unstable before transfer to another health

care facility—the Consolidated Omnibus Budget

Reconciliation Act (COBRA) of 1985 -and the

Omnibus Budget Reconciliation Act (OBRA) of 1990.

This stabilization mtist occur regardless of the

client’s financial ability to pay for services. ED

personnel who transfer clients to another institution

without first providing this initial stabilization can

incur substantial fines and penalties, as can the

hospital administration.

b. Clients have continued to seek health care services

in the ED, even with the proliferation of managed

health care plans and gatekeeping policies. The

financial integrity of the ED has been challenged

over the years due to the legal obligations of the ED

to provide service.

c. Retrospectively, financial reimbursement for

rendered services has been denied to EDs from

managed health care plans following a

determination that the client’s problem did not

constitute a true emergency

d. Additional legislation was enacted (Emergency

Medical Treatment and Active Labor Act EMTALA in

1988, 1989, 1990, and 1994) requiring that a

medical screening examination be performed on all

ED clients before solicitation of information about

ability to pay.3 This medical screening examination

must be inclusive enough to determine whether the

client is experiencing an emergency medical

condition requiring treatment or, in the case of a

pregnant woman, is experiencing labor contractions.

An emergency medical condition includes drug

abuse, hemodynamic instability, psychiatric illness,

intoxication, severe pan, and labor.

e. If a client has an emergency medical condition,

stabilization must be rendered. Stabilization is

interpreted to mean that deterioration of the client is

unlikely during possible transfer or discharge of the

client. Continued interpretations of this act have

expanded the facilities that come under EMTALA.

These include not only EDs. but also hospital owned

urgent care centers, anywhere unscheduled clients

appear for medical care, and off site locations that

are within a 250-yard zone of a main hospital that is

covered under the 2001 outpatient prospective

payment system. Violations of this legislation can

again result in fines and penalties.

2. CONSENT TO TREAT

a. Most adult clients seeking treatment in the ED give

voluntary consent to the standard and usual

treatment performed in this setting. In some

instances, however, a client is deemed unable to

give consent for treatment. This inability may be due

to the critical nature of the client’s illness or injury or

to other conditions, such as an altered level of

consciousness. In these instances, emergency care

may be rendered to the client under the implied

emergency doctrine. This doctrine assumes that the

client would consent to treatment to prevent death or

disability if the client were so able.

b. Children younger than the age of legal majority must

have the consent of their parent or legal guardian for

medical care to be rendered. Exceptions include (1)

emancipated minors, (2) minors seeking treatment

for communicable diseases, including sexually

transmitted diseases, injuries from abuse, and

alcohol or drug rehabilitation, and (3) minor-aged

females requesting treatment for pregnancy or

pregnancy-related concerns. Some states also allow

the adult caregiver with whom the child resides to

give treatment authorization even though that

caregiver may not be the parent.

c. The issue of informed consent in the ED is the same

as in any other health care setting. Adult clients

must he informed about the necessity of required

treatments, expected outcomes, and potential

complications. Clients must also be mentally

competent and understand the information being

explained. As in any other setting, a mentally

competent adult client always maintains the right to

refuse treatment or withdraw previously given

consent.

3. RESTRAINTS

a. Restraining a client while he or she is in the ED may

at times be necessary. The 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 injuring self or others and when

nonphysical methods of controlling the client are not

viable.

b. Restraints may not he used to control a client solely

for convenience or because of staffing issues.

c. When restraints are required, departmental and

hospital guidelines that are in compliance with Joint

Commission and the Centers for Medicare &

Medicaid Services must he followed.

d. A physician’s order for applying restraint as well as

the client’s behavior mandating the use of restraints

most be documented.

e. The 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 extremities.

f. The findings must be documented. Offering water to

the client and providing opportunities to urinate or

relieve other body needs are required, as is

documentation of this nursing care.

g. No client may be kept restraints against his or her

will unless the client’s behavior indicates the

existence of safety issues.

h. Behavior modification techniques used in an attempt

to release the client from restraints must also be

documented. The ED staff must receive appropriate

education pertaining to dealing with clients requiring

physical restraint.

i. Clients 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. THIs order mandates

that such clients be placed in a locked psychiatric

facility for their protection for a maximum of 72

hours. Within that 72-hour period, the client must be

evaluated by a psychiatrist to determine whether the

legal hold needs to be extended or whether the

client can be released.

4. MANDATORY REPORTING

a. Every state has mandatory reporting regulations that

affect emergency nurses. Incidents and conditions

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

authorities or to the Department of Public Health,

Department of Motor Vehicles, coroner’s offices, or

animal control agencies.

b. The types of incidents requiring reporting are

suspected child, sexual, domestic, and elder abuse;

assaults; motor vehicle crashes; communicable

diseases such as hepatitis, sexually transmitted

diseases, chicken pox, measles, mumps, meningitis,

tuberculosis, and food poisoning; first time or

recurrent seizure activity; death; and animal bites.

c. Every ED has written policies regarding these

mandatory reports.

5. EVIDENCE COLLECTION AND PRESERVATION

a. Recognition of unusual circumstances surrounding a

client’s injury or death is an important aspect of ED

nursing because of the associated legal implications.

Not only must tile legal authorities be notified, but

also, in many instances, the ED nurse may be

required to collect and preserve evidence taken from

the client. This evidence can include bullets,

weapons, clothing, and body fluid specimens.

b. All collected evidence must be identified by the

client’s name, hospital identification number, date

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. Once the evidence

has been collected, its preservation and the

maintenance of the “chain of custody” are extremely

important.

6. VIOLENCE

a. Violence directed against ED personnel has become

an issue of concern throughout the late 1990s and

into the 21st century. The environment inherent in

the ED, the emotional circumstances often

surrounding the illness or injury that affect both

clients and family members, and the increasingly

violent trends all play a role in this phenomenon.

b. Administrative changes have been made in some

EDs to enhance both public and health care worker

safety. These measures have included the

installation of items such as metal detectors, “panic

buttons,” bullet-proof glass, and lock- down doors at

public entrances; increasing the visibility of security

guards; using patrol guard dogs; and instituting

visitor control policies.

c. Changing the perception of the ED from one of fear

and isolation for both clients and family members is

also occurring.

d. Instituting family centered practices that recognize

tile importance of family participation and addressing

the emotional needs of clients and families is a trend

in ED management.

Following are areas to address

Recognizing potentially violent clients and

situations

Identifying verbally and physically abusive

signs from clients, family members, or friends

Understanding the importance of instinct or

gut , reactions

Using simple communication strategies to

defuse potentially problematic situations

Requiring clients to completely undress

before physical examination

Minimizing the presence of “potential

weapons” in client care areas such as

scalpels, needles, excess tubing attached to

oxygen flow meters, scissors, stethoscopes

worn around the neck, and personal jewelry.

Restraining clients, when necessary, using a

team approach.

Avoiding becoming a hostage in a volatile

situation

Having safety committee track all reported

assaults on clients and employees

Ensuring Occupational Safety and Health

Administration violence guidelines are

followed

Encouraging employees to report both verbal

and physical assaults.

B. ETHICAL ISSUES

1. UNEXPECTED DEATH

a. When death occurs in the ED setting, it is usually

sudden and unexpected, even if the client has had a

prolonged illness. I hr unexpected nature of the

death, or impending death, can present ethical

dilemmas for both the family survivors and the ED

personnel.87 One such issue deals with the length

to which resuscitation is performed. This is usually a

physician’s decision; however, family members may

at times have input. Allowing family members or

significant others to be present during client

resuscitation is becoming more common. This

practice is not necessarily disruptive to the

resuscitation process, and it can be of comfort to the

survivors and the involved ED personnel.

b. When death does occur, the ED nurse and the ED

physician have important roles in informing the

family:

i. Inform the family of the client’s death, and

refer to the deceased client by name.

ii. Provide the family with an explanation of the

course of events related to the death; use

simple explanations.

iii. Offer the family an opportunity to view the

body. If a child has died, allow the parent to

hold the child. Providing the parent with a

lock of the child’s hair may be comforting.

iv. Help the family to focus on decisions

requiring immediate attention such as taking

possession of the deceased person’s

valuables, arranging postmortem

examination if desired or required, identifying

possible organ or tissue donation, and

selecting a funeral home.

v. Inform family members when they can leave

the ED setting.

vi. Provide community agency referral as

needed.

2. ORGAN AND TISSUE DONATION

Issues related to potential organ or tissue donation

often arise in the ED setting. Once a potential donor

is identified, the surviving family members need to

be approached. A team approach involving a

physician, a nurse, arid possibly an organ

procurement coordinator is optimal. Utmost dignity

and professionalism must be maintained. Whatever

decision the family makes regarding organ or tissue

donation, that decision must be supported by health

Care personnel.

3. CHILD ABONDONMENT

States are beginning to pass child abandonment laws in

response to the number of newborn infants being

abandoned following birth. In general, the law allows

mothers to bring their newborn child to the ED and abandon

the child in the care of the ED personnel. The mother bears

no criminal responsibility. Local Departments of Social

Services are then contacted so the child can be placed in

their custody.

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PRINCIPLES OF EMERGENCY CARE

A. TRIAGE

Triage, a French word meaning “to sort,” refers to the process

of rapidly determining patient acuity. It is one of the most

important assessment skills needed by the emergency nurse.1

The triage process is based on the premise that patients who

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

other patients. A triage cistern identifies and categorizes

patients so that the most critical are treated first.

After the emergency nurse completes the initial assessment to

determine the presence of actual or potential threats to life,

appropriate interventions are initiated for the patient’s condition.

A history is obtained simultaneously with the assessment. A

systematic approach to the initial patient assessment

decreases the time required to identify potential threats and

minimizes the risk of overlooking a life-threatening condition.

Two 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.

B. PRIMARY SURVEY

The primary survey focuses on airway, breathing, circulation,

and disability and serves to identify life-threatening conditions

so that appropriate interventions can be initiated. Life-

threatening conditions related to airway, breathing, circulation,

and disability may be identified at any point during the primary

survey. When this occurs, interventions are started immediately

and before proceeding to the next step of the survey.

A =Airway with Cervical Spine Stabilization and/or

Immobilization.

1. Nearly all immediate trauma deaths occur because of

airway obstruction. Saliva, bloody secretions, vomitus,

laryngeal trauma, dentures, facial trauma, fractures, and the

tongue can obstruct the airway. Patients at risk for airway

compromise include those who have seizures, near-

drowning, anaphylaxis, foreign body obstruction, or

cardiopulmonary arrest. If an airway is not maintained,

obstruction of airflow occurs and hypoxia, acidosis, and

death may result.

2. Primary signs and symptoms in a patient with a

compromised airway include dyspnea, inability to vocalize,

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

face or neck. Airway maintenance should progress rapidly

from the least to the most invasive method.

3. Treatment includes opening the airway using the jaw-thrust

maneuver (avoiding hyperextension of the neck), 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. Patients should be

ventilated with 100% oxygen using a bag valve mask (BVM)

device before intubation or cricothyroidotomy.

4. Rapid sequence intubation is the preferred procedure for

securing an unprotected airway in the ED. It involves the

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

succinylcholine) to facilitate intubation while minimizing the

risk of aspiration and airway trauma.

5. Any patient with face, head, or neck trauma and or on

significant upper torso injuries should always be suspected

of cervical spine a neutral position) and or immobilized

during assessment of the airway. At the scene of the injury,

the cervical spine is immobilized with a rigid cervical collar

or a cervical immobilization device (CED) (also known as

‘head blocks”). Towel rolls are taped to a backboard on

either side of the head. Finally, the patient’s forehead is

secured to the backboard. Sandbags should not be used

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

patient must be log-rolled.

B =Breathing.

1. Adequate airflow through the upper airway does not ensure

adequate ventilation.

2. Breathing alterations are caused by many conditions,

including fractured ribs, pneumothorax, penetrating injury,

allergic reactions, pulmonary emboli, and asthma attacks.

3. Patients with these conditions may experience a variety of

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

emboli), paradoxic or asymmetric chest wall movement (e.g.

flail chest), decreased or absent breath sounds on the

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

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

tachycardia, and hypotension.

4. Every critically injured or ill patient has an increased

metabolic and oxygen demand and should have

supplemental oxygen.

5. High flow oxygen (100%) via a non-re-breather mask should

be administered and the patient’s response monitored. Life-

threatening conditions, such as tension pneumothorax and

flail chest, can severely compromise ventilation,

Interventions in these situations include BVM ventilation

with 100% oxygen, intubation, and treatment of the

underlying cause.

C = Circulation.

1. An effective circulatory system includes the heart, intact

blood vessels, and adequate blood volume.

2. Uncontrolled internal and/or external bleeding places a

person at risk for hemorrhagic shock.

3. A central pulse (e.g., carotid) should be checked because

peripheral pulses may be absent as a result of direct injury

or vasoconstriction.

4. If a pulse is palpated, the quality and rate of the pulse are

assessed.

5. Skin should be assessed for color, temperature, and

moisture.

6. Altered mental status is the most significant signs of shock.

7. Care must be taken when evaluating capillary refill in cold

environments because cold delays refill.

6. Intravenous (IV) lines are inserted into veins in the upper

extremities unless contraindicated, such as in a massive

fracture or an injury that affects limb circulation.

7. Two large-bore (14- to 16-gauge) IV catheters should be

inserted and aggressive fluid resuscitation initiated using

normal saline or Ringer’s lactate solution.

8. Direct pressure with a sterile dressing should be applied to

obvious bleeding sites. Blood samples are obtained for

typing to determine ABO and Rh group.

9. Type specific packed red blood cells should be

administered if needed. In an emergency (life-threatening)

situation, uncrossmatched blood may be given if immediate

transfusion is warranted.

10. The use of the pneumatic antishock garment (PASG) is a

temporary strategy that may be considered for pelvic

fracture bleeding with hypotension.4 The PASG is a three-

chambered suit that is applied to the patient’s legs and

abdomen and is inflated with a foot pump. Physiologically,

the PASG increases peripheral vascular resistance in the

patient’s lower extremities, thus elevating blood sure, and

works to control pelvic fracture bleeding.

11. Care must taken when deflating the garment. Rapid

deflation can result in a severe drop in peripheral vascular

resistance and blood pressurealternative devices to the

PASG include pelvic splints and belts.

D = Disability.

1. A brief neurologic examination completes the primary

survey. The degree of disability is measured by the patients

level of consciousness. Determining the patient’s response

verbal and/or painful stimuli is one approach to assessing

level consciousness. A simple mnemonic to remember is

AVPU: A = alert, V = responsive to voice, P = responsive to

pain, and U — unresponsive.

2. In addition, the Glasgow Coma Scale is used to assess the

arousal aspect of the patent’s consciousness.

3. Finally, the pupils should be also assessed for size, shape,

response to light, and equality.

C. SECONDARY SURVEY

After each step of the primary survey is addressed and any

lifesaving interventions are initiated, the secondary survey

begins.

The secondary survey is a brief, systematic process that is

aimed at identifying all injuries.

E=Exposure/Environmental Control

All trauma patients should have their clothes removed so

that a thorough physical assessment can be performed.

Once the patient is exposed, it is important to limit heat loss

and prevent hypothermia by using warming blankets,

overhead warmers, and warmed IV fluids.

F=Full Set of Vital Signs/Five Interventions/Facilitate

Family Presence.

1. A complete set of vital signs, including blood pressure, heart

rate, respiratory rate, and temperature, should be obtained

after the patient is exposed.

2. Blood 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.

3. At this point, it must be determined whether to proceed with

the secondary survey or to perform additional interventions.

The availability of other team members often influences this

decision. For patients who have sustained significant

trauma and/or have required lifesaving interventions during

the primary survey, the following five interventions should

be performed at this time:

a. The patient should he monitored h

electrocardiogram (ECG) for heart rate and rhythm.

b. The pulse oxymetry should ho initiated and oxygen

saturation (Sp02) monitored.

c. An indwelling catheter should be inserted to monitor

urine output and to check for hematuria, An

indwelling catheter should not be inserted if a

urethral tear is suspected. Patients with pelvic

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

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

digital rectal examination, are at risk for a urethral

tear or transection. A retrograde urethrogram should

be obtained before a catheter is inserted.

d. An Orogastric or a nasogastric tube should be

inserted to provide gastric decompression and

emptying to reduce the risk of aspiration and to test

the contents for blood. A nasogastric tube should not

be placed in the nares of a patient suspected of

having facial fractures or a basilar skull fracture

because the tube could enter the brain through the

cribriform plate; rather, it should be placed orally.

e. Laboratory studies for typing and crossmatching,

hematocrit, hemoglobin, blood urea nitrogen,

creatinine, blood alcohol, toxicology screening,

arterial blood gas (ABGs), electrolytes, coagulation

profile, liver enzymes, cardiac enzymes, and

pregnancy should be facilitated.

Facilitating family presence (FP) completes this

step of the secondary survey. Research supports the

benefits of FP during resuscitation and invasive

procedures to patients, families, and staff. Patients

reported that having family members present comforted

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

remind the health care team of their “personhood.

Family members who wished to be present during

invasive procedures and resuscitation viewed

themselves as active participants in the care process.

They also believed that they provided comfort to the

patient and that it was their right to be with the patient.

Staff nurses reported that family members who

participated in FP functioned as “patient helpers” (e.g.

providing support) and “staff helpers” (e.g., acting as a

translator) and reinforced that FP helped to convey the

sense of the patient’s personhood. Should a family

member request FP during resuscitation or invasive

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

designated to explain care delivered and be available to

answer questions.

G = Give Comfort Measures.

1. Provision of comfort measures is of paramount importance

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

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

ED.

2. Many EDs have developed nurse-initiated pain

management protocols to treat pain early, beginning at

triage. Pain management strategies should include a

combination of pharmacologic (e.g. nonsteroidal anti-

inflammatory drugs, IV opioids) and non-pharmacologic

(e.g., imagery, distraction) measures.

3. Emergency nurses play a pivotal role in ongoing pain

management because of their frequent contact with

patients. General 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.

H = History and head-to-toe assessment

1. History should include following questions

a. What is the chief complaint?

b. What caused the patient to seek attention?

c. What are the patient subjective complaints?

d. What is the patient’s description of pain (e.g..

location, duration. quality, character)?

e. What are witnesses’ (if any) descriptions of the

patient’s heha‘ior since the onset?

f. What is the patient’s health history?

The mnemonic AMPLE is a memory aid that

prompts the nurse to ask about the following:

A = Allergies

M = Medication history

P = Past health history (e.g., preexisting medical

and/or psychiatric conditions, previous

hospitalizations/surgeries, smoking history, recent

use of drugs/alcohol, tetanus immunization, last

menstrual period, baseline mental status).

L= Last meal

E= Events/environment preceding illness or injury

2. Head, Neck, and Face

The patient should be assessed for general

appearance, skin color, and temperature.

The eyes should be evaluated for extraocular

movements.

A disconjugate gaze is an indication of neurologic

damage.

Battle’s sign, or bruising directly behind the ear(s),

may indicate a fracture of the base of the posterior

portion of the skull.

“Raccoon eyes,” or periorbital ecchymosis, is usually

an indication of a fracture of the base of the frontal

portion of the skull.

The tympanic membranes and external canal are

checked for blood and cerebrospinal fluid.

Clear drainage from the ear or nose should not be

blocked.

The airway is assessed for foreign bodies, bleeding,

edema, and loose or missing teeth.

Assess for difficulty swallowing, movement.

The trachea is palpated and visualized to determine

whether it is midline. A ‘deviated trachea may signal,

a life-threatening tension pneumothorax.

Subcutaneous emphysema may indicate

laryngotracheal disruption

A stiff or painful neck area may signify a fracture of

one or more cervical vertebrae.

The cervical spine must be protected using a rigid

collar and supine positioning. Patients must be

logrolled while maintaining cervical spine

immobilization when movement is necessary.

3. Chest.

The chest is examined for paradoxic chest

movements and large sucking chest wounds.

The sternum, clavicles, and ribs are palpated for

deformity and point tenderness.

The chest is assessed for pain on palpation,

respiratory distress, decreased breath sounds,

distant heart sounds, and distended neck veins

In addition to tension pneumothorax and open

pneumothorax, the patient should be evaluated for

rib fractures, pulmonary contusion, blunt cardiac

injury, and haemothorax.

A 12-lead ECG should be obtained, particularly on a

patient with known or suspected heart disease.

The ECG should be done to detect dysarrhythmias

and evidence of myocardial ischemia or infarction.

4. Abdomen and Flanks.

The abdomen and flanks are more difficult to

assess. Frequent evaluation for subtle changes in

the abdominal examination is essential. Motor

vehicle collisions and assaults can cause blunt

trauma. Penetrating trauma tends to injure specific,

solid organs (e.g., spleen).

Decreased bowel sounds may indicate a temporary

paralytic ileus.

Bowel sounds in the chest may indicate a

diaphragmatic rupture.

The abdomen is percussed for distention e.g.

tympany (excessive air), dullness [excessive fluid])

and palpated for peritoneal irritation.

Intra-abdominal hemorrhage is suspected, a focused

abdominal sonography for trauma (FAST) to

determine the presence of blood in the peritoneal

space (hemoperitoneum) is preferred. This

procedure is noninvasive and can be performed

quickly at the bedside.

An alternative, a diagnostic peritoneal lavage, may

be considered. Before this procedure, a gastric tube

and a bladder catheter must be inserted to

decompress these organs and reduce the possibility

of perforation.

5. Pelvis and Perineum.

The pelvis is gently palpated, not rocked. If pain is

elicited, it may indicate a pelvic fracture.

The genitalia are inspected for bleeding and obvious

injuries.

A rectal examination is performed to check for blood,

a high-riding prostate gland, and loss of sphincter

tone.

Assess for bladder distention, hematuria, dysuria, or

the inability to void.

6. Extremities.

The upper and lower extremities are assessed for

point tenderness, crepitus, and deformities.

Injured extremities are splinted above and below the

injury to decrease further soft tissue injury and pain.

Grossly deformed, pulseless extremities should be

realigned and splinted.

Pulses are checked before and after movement or

splinting of an extremity.

A pulseless extremity is a time-critical vascular or

orthopedic emergency.

Extremities are also assessed for compartment

syndrome. This occurs as pressure and swelling

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

anterior compartment of lower leg), compromising

the viability of the extremity muscles, nerves, and

arteries.

I = Inspect the posterior surface

Inspect the Posterior Surfaces. The trauma patient should

always be logrolled (while maintaining cervical spine

immobilization) to inspect the patient’s posterior surfaces. The

back is inspected for ecehymoses, abrasions, puncture

wounds. cuts, and obvious deformities. The entire spine is

palpated for misalignment, pain, deformity.

INTERVENTION AND EVALUATION

Once do secondary survey is complete, all findings are

recorded. All patients should Be evaluated to determine their

need for tetanus prophylaxis. Information about the patient’s

past vaccination history and the condition of any wounds is

needed in order to make an appropriate decision.

Regardless of the patient’s chief complaint, ongoing patient

monitoring and evaluation of interventions are critical in an

emergency situation.

The nurse is responsible for providing appropriate interventions

and assessing the patient’s response. The evaluation of airway

patency and the effectiveness of breathing will always assume

highest priority. The nurse will monitor 02 saturation and ABGs

to help determine the patient’s progress in these areas. Level of

consciousness, vital signs, quality of peripheral pulses, urine

output, and skin temperature, color, and moisture provide key

information about circulation and perfusion and are also closely

monitored.

Depending on the patient’s injuries and/or illness, the patient

may be (I) transported for diagnostic tests such as X-ray or CT

scan: (2) admitted to a general unit, telemetry, or an intensive

care unit; or (3) transferred to another facility. The emergency

nurse is responsible for monitoring the critically ill patient during

intrafacility and interfacility transport and notifying the team

should tile patient’s condition change from baseline. Nurses

accompanying patients on transports must be competent in

advanced life-support measures.

Death in the Emergency Department

Unfortunately, there are a number of emergency

patients who do not benefit from the skill, expertise, and

technology available in the ED. It 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.

The emergency nurse should recognize 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 making mortuary arrangements. The

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

grieve and accept tile death. The emergency nurse plays a

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. Certain tissues and

ure:iiis such as cornea, heart valves, skin, bone, and kidneys

can be harvested from patients after death.

Approaching families about donation after an

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

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

positive step in the grieving process. Organ 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.

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Summary

Till 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.

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

rather than unknown. Trauma 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.

Assignment

solve the 10 multiple choice questions, 10 marks

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BIBLIOGRAPHY:-

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

Nursing Assessment and Management of Clinical Problem

(7th ed) Mosby, pg no. 2552-66.

2. Black J.M. Hawk, J.H. (2005) Medical Surgical Nursing

Clinical Management for Positive Outcomes. (7th ed)

Elsevier, pg no. 2441-54.

3. Brunner S. B., Suddarth D.S. The Lippincott Manual of Nursing practice J.B.Lippincott. Philadelphia, pg no. 32051-59

4. Understanding medical surgical nursing, F A Davis 6th edition, elsieiver publication pg. no. 210-224.

5. www.ene.org/issues.html

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1. INEFFECTIVE AIRWAY CLEARANCEA compromised or ineffective airway max’ he due to

either complete or partial airway obstruction. Common causes

of airway compromise include the presence of a foreign object in the airway, airway edema, airway infection, facial or airway injury, and tongue obstruction.

CLINICAL MANIFESTATIONS Absence of respirations Drooling stridor, intercostal or substernal retractions cyanosis, a mid agitation A decreased level of Consciousness may lead to airway

compromise as a result of obstruction of the posterior pharynx by the relaxed tongue.

ManagementRemove Obstruction. If an obstruction is present, the airway should be opened by a chin lift or jaw thrust maneuver. If either of these maneuvers opens the client’s airway, patency is maintained via the insertion of a nasopharyngeal or oral airway device. If these maneuvers fail to relieve the obstruction, more aggressive interventions must he instituted, such as

performing abdominal or chest thrusts if an aspirated foreign object is the suspected cause

suctioning the oral cavity to remove secretions or visible foreign objects

Intubating via the nasal or oral route Using a laryngeal mask airway (LMA), Assisting with creating a surgical airway via a

cricothyroidotomy.

IntubateIn some cases, oral or nasal intubation may require the use of rapid-sequence induction (RSI) This procedure is used in awake clients who require intubation either to maintain the airway or as a mechanism to provide adequate ventilation. RSI is most frequently used in clients who have sustained a head or spinal injury and in clients who are rapidly tiring from the effort of maintaining respirations. Rb! involves

Establishing venous access

Hyperventilating the client with 100% oxygen, Administering intravenous (IV) lidocaine I op/kg to blunt

any transient increase in intracranial pressure from the actual intubation procedure

Administering an IV general barbiturate or anesthetic medication such as thiopental 3 to 5 mg/kg,

Verify Tube Placement After the intubation procedure, the ED nurse is

immediately responsible for auscultation of the client’s chest during assisted ventilation to confirm the presence of equal bilateral breath sounds.

If breath sounds are heard over the epigastric area, the tracheal tube must be removed, the client hyperventilated, and the procedure reattempted.

Breath sounds heard more prominently over the upper right chest indicate that the tracheal tube has advanced far into the right main bronchus. The tube needso be pulled-hack and breath sounds reassessed.

Once the presence of equal and bilateral breath sounds is confirmed, the tube is secured in place and a chest film is obtained to document correct tube placement.

Securing and maintaining a patent airway constitutes the first priority in any ED client. Other treatments directed at the cause of airway compromise are then instituted. These measures may include administration of IV medications if infection or local edema of the airway is present.

Immobilize the Spine

If the client with an actual or potential airway problem has also sustained a traumatic injury, simultaneous stabilization of the client’s cervical, thoracic, and lumbar spine must be instituted and maintained to prevent any further possible spinal injury.

Manually stabilizing the client’s head and cervical spine

Applying a hard cervical collar around the client’s

nuchal area Placing the client on a long, rigid backboard Securing the client to the backboard Placing immobilization devices, such as rolled

towels, at the side of the client’s head and neck, and

Placing a strip of adhesive tape across the client’s forehead and immobilization devices and then onto the backboard.

2. INEFFFECTIVE BREATHING PATTERNHYPERVENTILATIONCLINICAL MANIFESTATIONS

Fast respiratory rate Numbness Tingling sensation Carpal or pedal spasm Anxiety

MANAGEMENT Instruct patient to take slow breath Instruct him to breath in paper bag and rebreath their

own carbon dioxide

HYPOVENTILATIONClinical Manifestaions

RESPIRATORY RATE LESS than 12/min Decreased level of consciousness Pallor Cyanosis

Management Administer high flow oxygen by bag valve mask

3. IMPAIRED GAS EXCHANGE Abnormal lung sound rhonchi, wheezing Pneumothorax (diminished or absent breath sound in

affected side) Asymmetrical hest movements (trauma or flail chest)

4. TRAUMATIC PNEUMOTHORAX

Cause Trauma to chest

Clinical manifestation Penetrating injury or Open wound on chest Pain

Management Administer oxygen at high flow via face mask Apply occlusive dressing on open chest wound Insert 14-16 gauze needle in anterior chest at 2nd

intercostals space in midclavicular line to drain the air. Place chest tube with collection bag or suction tube

5. FLAlL ClESTA flail chest involves serious rib fractures. It 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. The fractured segment has no connection with the remaining rib cage. This segment then moves in a direction opposite that of the rest of the chest wall during the processes of inhalation and exhalation so-called paradoxical chest wall movement (Figure 84-9). Respiratory distress is present, as are skin pallor and cyanosis. Treatment involves nasal or tracheal intubation and mechanical ventilation with positive end-expiratorv pressure (PEEP). Pulmonary contusions are commonly present in conjunction with a flail chest, and within 24 to 48

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