EMERGENCY ROOM NURSING

Care given to patients with urgent and criticalneeds

•
Also for non-urgent cases or whatever thepatient or family considers an emergency
•
Serious life-threatening cardiac conditions(Myocardial infarction, Acute heart
failure,Pulmonary edema Cardiac dysrhythmias)

The Emergency Nurse

•
Applies the ADPIE on the human responsesof individuals in all age groups whose careis made
difficult by the limited access topast medical history and the episodicnature of their health care
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Triage and prioritization.
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Emergency operations preparedness.
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Stabilization and resuscitation.
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Crisis intervention for unique patientpopulations, such as sexual assaultsurvivors.
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Provision of care in uncontrolled andunpredictable environments.
•
Consistency as much as possible across thecontinuum of care

The Nursing Process

Provides logical framework for problemsolving in this environment

Nursing assessment must be continuous,and nursing diagnoses change with thepatient’s

condition

Although a patient may have severaldiagnoses at a given time, the focus is onthe most life-
threatening ones

Both independent and interdependentnursing interventions are required

Emergency Nursing in Disasters
•
The emergency nurse must expand his orher knowledge base to encompassrecognizing &
treating patients exposed tobiologic and other terror weapons
•
The emergency nurse must anticipatenursing care in the event of a masscasualty incident.
Documentation of Consent
•
Consent to examine and treat the patient ispart of the ER record.
•
The patient must consent to invasiveprocedures unless he or she is unconsciousor in critical
condition and unable to makedecisions.
Helping Them Cope With Sudden Death
•
 Take the family to a private place.
•
Talk to the family together, so they canmourn together.
•
Reassure the family that everythingpossible was done; inform them of thetreatment rendered.
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Show the family that you care by touching,offering coffee, and offering the services of the chaplain.

•Helping Them Cope With Sudden Death

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Take the family to a private place.
•
Talk to the family together, so they canmourn together.
•
Reassure the family that everythingpossible was done; inform them of thetreatment rendered.
•
Show the family that you care by touching,offering coffee, and offering the services of the chaplain.

If the patient is unconscious and brought tothe ER without family or friends, this factshould be
documented
•
After treatment, a notation is made on therecord about the patient’s condition ondischarge or
transfer and aboutinstructions given to the patient and familyfor follow-up care.
Exposure to Health Risks
•
All emergency health care providers shouldadhere strictly to standard precautions forminimizing
exposure.
•
Early identification and adherence totransmission-based precautions forpatients who are
potentially infectious iscrucial.
•
ER nurses are usually fitted with a personalhigh-efficiency particulate air (HEPA)-filtermask
apparatus to use when treatingpatients with airborne diseases.
Providing Holistic Care
•
Sudden illness or trauma is a stress tophysiologic and psychosocial homeostasisthat requires
physiologic & psychologicalhealing.
•
When confronted with trauma, severedisfigurement, severe illness, or suddendeath, the family
experiences severalstages of crisis beginning with anxiety, andprogress through denial, remorse &
guilt,anger, grief & reconciliation.
•
The initial goal for the patient and family isanxiety reduction, a prerequisite torecovering the
ability to cope.
•
Assessment of the patient and family’spsychological function includes evaluatingemotional
expression, degree of anxiety,and cognitive functioning.
Nursing Diagnoses
•
Possible nursing diagnoses include: Anxietyrelated to uncertain potential outcomes of theillness or
trauma and ineffective individualcoping related to acute situational crises
•
Possible diagnoses for the family include:Anticipatory grieving and alterations in familyprocesses
related to acute situational crises
Patient-Focused Interventions
•
Those caring for the patient should actconfidently and competently to relieveanxiety.
•
Reacting and responding to the patient in awarm manner promotes a sense of security.
•
Explanations should be given on a levelthat the patient can understand, becausean informed
patient is better able to copepositively with stress.
•
Human contact & reassuring words reducethe panic of the severely injured personand aid in
dispelling the fear of theunknown.
•
The unconscious patient should be treatedas if conscious (i.e. touching, calling byname,
explaining procedures)
•
As the patient regains consciousness, thenurse should orient the patient by statinghis or her name,
the date, and the location.
Family-Focused Interventions
•
The family is kept informed about wherethe patient is, how he or she is doing, andthe care
that is being given.
•
Allowing the family to stay with the patient,when possible, also helps allay theiranxieties.
•
Additional interventions are based on theassessment of the stage of crisis that thefamily is
experiencing.

Discharge Planning
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Instructions for continuing care are given tothe patient and the family or significantothers.
•
All instructions should be given not onlyverbally but also in writing, so that thepatient can refer to
them later.
•
Instructions should include informationabout prescribed medications, treatments,diet, activity, and
contact info as well asfollow-up appointments.
Principles of Emergency Room CareTriage
: comes from the French word
trier
, whichmeans "to sort;” A method to quickly evaluate andcategorize the patients requiring the
mostemergent medical attention.
ER Triage
•
Emergent
(immediate): patients have thehighest priority; must be seen
immediately
•
Urgent
(delayed or minor): patients haveserious health problems, but notimmediately life-threatening
ones; seenw/in 1 hour
•
Non-urgent
(minor or support): patientshave episodic illnesses addressed within 24hours.
Determination of Priority in ER Triage
:Classified based on principle to benefit the largestnumber of people
Determination of Priority in Field Triage

Critical clients are given lowest priority

Victims who require minimal care and can beof help to others are treated first.
1.
Red
– Emergent (immediate)
2.
Yellow
– Immediate (delayed)
3.
Green
– Urgent (minor)
4.
Blue
– Fast track or psychological supportneeded
5.
Black
– Patient is dead or progressingrapidly towards death
•
Triage Tags should be used on all callsinvolving 3 or more patients.
•
The general placement location should be onone of the patient’s arms.
•
When a triage tag has been utilized, rememberto document the tag number in the historyportion of
your run report.
“E”– Cart
•
Located in designated areas where medicalemergencies and resuscitation is needed
•
Purpose: to maximize the efficiency in locatingmedications/supplies needed for
emergencysituations.
•
Drawer 5:
Contains
respiratory supplie
ssuch as oxygen tubing, a flow meter, a faceshield, and a bag-valve-mask device fordelivering
artificial respirations
•
Drawer 4:
Contains
suction supplies
&
gloves
•
Drawer 3:
Contains
intravenous fluids
•
Drawer 2:
Contains equipment forestablishing
IV access
, tubes for laboratorytests, and syringes to flush medication lines.
•
Drawer 1:
Contains
medications
neededduring a code such as epinephrine, atropine,lidocaine, CaCl
2
and NaHCO
3
•
The back of the cart usually houses the cardiacboard.
Assessment and Intervention in the ERThe Primary Survey
: Focuses on stabilizing life-threatening conditions; employs the
ABCDMethodThe ABCD Method
•
A
irway - Establish the airway
•
B
reathing - Provide adequate ventilation
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C
irculation - Evaluate & restore cardiacoutput by controlling hemorrhage,preventing & treating
shock, andmaintaining or restoring effectivecirculation
•
D
isability - Determine neurologic disabilityby assessing neuro function using the
Glasgow Coma ScaleEye openingEye opening responseresponse
SpontaneousSpontaneous To voice To voice To pain To painNoneNone 44332211
VerbalVerbal responseresponse
OrientedOrientedConfusedConfusedInappropriate wordsInappropriate wordsIncomprehensible
soundsIncomprehensible soundsNoneNone 5544332211
Motor responseresponse
Obeys commandObeys commandLocalizes painLocalizes
painWithdrawsWithdrawsFlexionFlexionExtensionExtensionNoneNone 665544332211
Assess and Intervene: The Secondary Surveyincludes:
•
A complete health history & head-to-toeassessment
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Diagnostic & laboratory testing
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Application of monitoring devices
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Splinting of suspected fractures
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Cleaning & dressing of wounds
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Performance of other necessary interventionsbased on the patient’s condition.
Airway Obstruction
•
An acute upper airway obstruction is ablockage of the upper airway, which can be inthe trachea,
laryngeal (voice box), or bronchiareas
•
Causes
: Viral and bacterial infections, fire orinhalation burns, chemical burns and reactions,allergic
reactions, foreign bodies, and trauma.
o
In adults, aspiration of a bolus of meatis the most common cause.
o
In children, small toys, buttons, coins,and other objects are commonlyaspired in addition to food.
Clinical Manifestations
1 . C h o k i n g 2 . A p p r e h e n s i v e a p p e a r a n c e 3.Inspiratory &
expiratory stridor4 . L a b o r e d b r e a t h i n g 5 . F l a r i n g o f n o s t r i l s 6.Use
of accessory muscles (suprasternal &intercostal retractions)
7.
ñ
anxiety, restlessness, confusion8.Cyanosis & loss of consciousness develops
ashypoxia worsens.
Assessment and Diagnostics
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Involves simply asking whether the patient ischoking & requires help
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If unconscious, inspection of the oropharynxmay reveal the object.
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X-rays, laryngoscopy, or bronchoscopy mayalso be performed.
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For elderly patients, sedatives & hypnoticmedications, diseases affecting motorcoordination, &
mental dysfunction are riskfactors for asphyxiation of food.
•
Victims cannot speak, breath or cough.
•
If victim can breathe spontaneously, partialobstruction should be suspected; the victim
isencouraged to cough it out.
•
If the patient has a weak cough, stridor, DOB &cyanosis, do the Heimlich.
•
After the obstruction is removed, rescuebreathing is initiated; if the patient has nopulse, start
cardiac compressions.
Head-Tilt-Chin-Lift Maneuver
1.Place the patient on a firm, flat surface.2.Open the airway by placing
one hand onthe victim’s forehead, and apply firmbackward pressure with the palm to tilt
thehead back.3.Place the fingers of the other hand underthe bony part of the lower
jaw near thechin and lift up.
4.
Bring the chin and teeth forward to supportthe jaw.
Jaw-Thrust Maneuver
1.Place the patient on a firm, flat surface.
2.
Open the airway by placing one hand oneach side of the victim’s jaw, followed bygrasping and
lifting the angles, thusdisplacing the mandible forward.
Oropharyngeal Airway Insertion
A semicircular tube or tube-like plastic deviceinserted over the back of the tongue into the
lowerpharynxUsed in a patient who is breathing spontaneouslybut unconscious.
ET Intubation: Indications
1.To establish an airway for patients whocannot be adequately intubated with
anoropharyngeal airway.2.To bypass an upper
airway obstruction3 . T o p r e v e n t a s p i r a t i o n 4.To permit connection of
the patient to aresuscitation bag or mech. ventilator
5.
To facilitate removal of tracheobronchialsecretions
Cricothyroidotomy
•
Used in the following emergencies in w/c ETintubation is
contraindicated:1.Extensive maxillofacial trauma2 . C e r v i c a l s p i n e i n j u r i e s 3 .
L a r y n g o s p a s m 4 . L a r y n g e a l e d e m a 5.Hemorrhage into neck
tissue6.Laryngeal obstruction
Nursing Diagnoses For Airway Obstruction
1.Ineffective airway clearance due to obstructionof the tongue, object, or fluids (blood,
saliva)2.Ineffective breathing pattern due toobstruction or injury
Hemorrhage
•
Bleeding that may be external, internal or both
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External: Laceration, avulsion, GSW, stabwound
•
Internal: Bleeding in body cavities and internalorgans
Assessment
•
Results in reduction of circulating bloodvol., w/c is the principal cause of shock
•
Signs and symptoms of shock:1 . C o o l , m o i s t s k i n
2 . H y p o t e n s i o n 3 . T a c h y c a r d i a 4.Delayed capillary
refill5 . O l i g u r i a
Management

Fluid Replacement

Two large-bore intravenous cannulae areinserted to provide a means for fluid and
bloodreplacement, and blood samples are obtainedfor analysis, typing, & cross-matching.

Replacement fluids may include

isotonicsolutions
(LRS, NSS), colloid, and bloodcomponent therapy.
•
Packed RBCs
are infused when there ismassive hemorrhage
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In emergencies,
O(-) blood
is used for womenof child-bearing age.
•
O(+) blood
is used for men andpostmenopausal women.
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Additional platelets and clotting factors aregive when large amounts of blood is needed.
Control of External Hemorrhage

Physical assessment is done to identify area of the hemorrhage.

Direct, firm pressure is applied over thebleeding area or the involved artery.

A firm pressure dressing is applied, and theinjured part is elevated to stop venous &capillary
bleeding if possible.

If the injured area is an extremity, it isimmobilized to control blood loss.

Control of Bleeding: Tourniquets

Applied only as a
last resort
just proximal tothe wound and tied tightly enough to controlarterial blood flow; tag the client with
a “T”stating the location and the time applied

Loosened periodically to prevent irreparablevascular on neuro damage

If still with arterial bleeding, remove tourniquetand apply pressure dressing

If traumatically amputated, the tourniquetremains in place until the OR.

Control of Internal Bleeding
•
Watch out for tachycardia, hypotension, thirst,apprehension, cool and moist skin, or
delayedcapillary refill.
•
Packed RBC are administered at a rapid rate,and the patient is prepped for OR.
•
Arterial blood is obtained to evaluatepulmonary perfusion & to establish baselinehemodynamic
parameters
•
Patient is maintained in a supine position andclosely monitored.
Hypovolemic Shock

A condition where there is loss of effectivecirculating blood volume due to rapid fluid lossthat can
result to multi-organ failure

Causes1.Massive external or internal bleeding2.Traumatic, vascular, GI and

pregnancyrelated3 . B u r n s
Nursing Diagnoses for Hypovolemic Shock
1.Altered tissue perfusion related to failingcirculation2.Impaired
gas exchange related to a V-Pimbalance
3.
Decreased cardiac output related todecreased circulating blood volume
Clinical Manifestations
1.Weakness, lightheadedness, and
confusion2 . T a c h y c a r d i a 3 . T a c h y p n e a 4 . D e c r e a s e i n p u l s e
pressure5 . C o o l c l a m m y s k i n 6.Delayed capillary refill
Hypovolemic Shock: Management
1.Rapid blood and fluid replacement; bloodcomponent therapy optimizes cardiac
preload,correct hypotension, & maintain tissueperfusion2.Large-bore intravenous
needles or cathetersare inserted into peripheral vv.3.A central venous pressure
catheter may alsobe inserted in or near the RA.
4.
LRS approximates plasma electrolytecomposition and osmolarity5.A Foley catheter is
inserted to record urinaryoutput every hour; urine volume indicatesadequacy of kidney
perfusion6.Ongoing nursing surveillance of the totalpatient is maintained to assess
the patient’sresponse to treatment; a flow sheet is used todocument parameters
7.
Lactic acidosis is a common side effect &causes poor cardiac performance
Wounds
•
A type of physical trauma wherein the skin istorn, cut or punctured (
open
wound), or whereblunt force trauma causes a contusion (
closed
wound).
•
Specifically refers to a sharp injury whichdamages the dermis of the skin.
•
Types of Wounds
1.
Open
(Incised wound, Laceration,Abrasion, Puncture wound, Gunshot wound)
2.
Closed
(Contusion, Hematoma, Crushinginjury)
Incised Wound
•
A clean cut by a sharp edged object such asglass or metal.
•
As the blood vessels at the wound edges arecut straight across, there may be profusebleeding
Laceration
•
Ripping forces or rough brushing against asurface which can cause rough tears in theskin or
lacerations.
•
Laceration wounds are usually bigger and cancause more tissue damage due to the size of the
wound.
Abrasion
Superficial wounds that occur at the surface of the skin.

Friction burns and slides can cause abrasion

Characteristic in the way that only the topmost layer of the skin is scrapped off.

Bleeding is not profuse though wounds

Puncture Wound
•
Small entry site
•
Though not large in surface area, wounds aredeep and can cause great internal damage.
Gunshot Wound (GSW)
•
Caused by firing bullets or any other smallarms.
•
Have a clean entry site but a large and raggedexit site.
Contusion a.k.a. bruise:
Caused by blunt forcetrauma that damages tissue under the skin
Hematoma:
Also called a blood tumor
•
Caused by damage to a blood vessel that inturn causes blood to collect under the skin
•
Caused by a great or extreme amount of forceapplied over a long period of time
Patterned Wound
: Wound representing theoutline of the object (e.g. steering wheel) causingthe wound
Management: Wound Cleansing
1.Hair around wound may be shaved.2.NSS is used to
irrigate the wound.3.Betadine & hydrogen peroxide are only usedfor initial
cleaning & aren’t allowed to get deepinto the wound without thorough rinsing.4.Use local or
regional block anesthetics if indicated.
Wound Management
1.Use of antibiotics depends on how the injuryoccurred, the age of the wound, &
the risk forcontamination2.Site is immobilized & elevated to limitaccumulation of
fluid3.Tetanus prophylaxis is administered based onthe condition of the wound and
theimmunization status
Wound Healing: By First Intention
•
Occurs when tissue is cleanly incised and re-approximated and healing occurs
withoutcomplications.
•
The incisional defect re-epithelizes rapidly andmatrix deposition seals the defect.
Wound Healing: By Second Intention
•
Healing occurs in open wounds.
•
When the wound edges are not approximatedand it heals with formation of granulationtissue,
contraction and eventual spontaneousmigration of epithelial cells.
Wound Healing: By Third Intention
•
Occurs when a wound is allowed to heal openfor a few days and then closed as if primarily.
•
Such wounds are left open initially because of gross contamination.
Trauma
•
The unintentional or intentional wound orinjury inflicted on the body from a
mechanismagainst w/c the body cannot protect itself
•
Leading cause of death in children and inadults younger than 44 y/o
•
Alcohol & drug abuse are implicated in bothblunt & penetrating trauma
•
Collection of Forensic Evidence:
Included indocumentation are the ff:1 . D e s c r i p t i o n s o f a l l
wounds2 . M e c h a n i s m o f i n j u r y 3 . T i m e o f e v e n t s 4.Collection of
e v i d e n c e 5.Statements made by the patient
•
If suicide or homicide is suspected in adeceased patient, the medical examiner willexamine the
body on site or have it moved tothe medico-legal office for autopsy.
•
All tubes & lines are left in place.
•
Patient’s hands are covered with paper bags toprotect evidence.
Injury Prevention Components
1.
Education:
Provide information andmaterials to help prevent violence, and tomaintain safety at home and in
vehicles.
2.
Legislation:
Provide universal safetymeasures without infringing on rights(Seatbelt Law).
3.
Automatic Protection:
Provide safetywithout requiring personal intervention(Airbags, seatbelts).High incidence of injury to
holloworgans, particularly the smallintestinesThe liver is the most frequently injuredsolid organ.High
velocity missiles create extensivetissue damage.
Intra-abdominal Injuries: Blunt (MVA, falls,blows)
Associated with extra-abdominal injuries to chest,head, extremityIncidence of delayed & trauma-
relatedcomplications is higherLeads to massive blood loss into the peritonealcavity
Trauma: Assessment
1.
Inspection
of abdomen for signs of injury(bruises, abrasions)
2.
Auscultation
of bowel sounds
3.
Watch out for signs of peritonealirritation
like distention, involuntaryguarding, tenderness, pain, muscularrigidity, or rebound tenderness
togetherwith absent BS.
Trauma: Diagnostic Findings
1.
Urinalysis
to detect hematuria
2.
Serial hematocrit
to detect presence orabsence of bleeding
3.
WBC count
to detect elevation associatedwith trauma
4.
Serum amylase
to detect pancreatic orGIT injury