Emergency Nursing. Triage. Black tag PDF

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Emergency nursing 

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Emergency Management o Care given to patients with urgent and critical needs  What is it? Actuality versus reality  Care for patients in the emergency care industry  Skilled in caring for pt when there has yet to be a diagnosis made or cause of problem is still unknown  Non emergent populations- homeless, urgent care patients, common aliments (using ER for PC needs) o Most common reasons for ED visits  Men: Belly aches, pains, cramps, chest pain, back problems, headaches, general or nonspecific pain, cuts on arms or legs, SOB, teeth/ gum problems, cough, leg symptoms  Women: belly aches, pain, cramps, chest pain, headaches, back problems, pregnancy worries, general or nonspecific pain, SOB, throat complications, cough, teeth/ gum problems o Legality – EMTALA  Passed to ensure public access to emergency services was provided despite the ability to pay  Tx and labor act serves to provide medical screenings for any individual who comes to ED and requests them Disaster Nursing o Another component of Emergency Nursing o Includes Mass Casualty, Terrorism, Environmental Disasters

Assessment 

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Triage- “to sort” o System based on Priority of Care o Universal system using color codes  Non-emergent- green  Urgent- yellow  Emergent- red, highest priority  Black- death or already dead, mass causality event in the field o Five Level Emergency Severity Index Assess and intervene on primary and secondary survey Primary Survey o A, B, C, D, E o Airway, breathing, circulation, disability, exposure to environment Secondary Survey o F, G, H, I

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Full VS, give comfort, hx collection, inspect of posterior surface

Emergency Severity Index (ESI)    

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Algorithm to provide clinically relevant stratification, couples pt into 5 groups 1 is the most urgent and 5 is the least urgent Consider the acuity of resources around you ESI-1= Unstable – Obvious life threatening, seen immediately by physician o Is the pt in imminent danger of dying? o Ex) cardiac arrest, intubate trauma pt, OD with bradypnea, severe respiratory distress ESI-2= Threatened – Likely life threatening, continuous monitoring, seen within 10 minutes o Is this a high risk pt who should not wait to be seen? o Abnormal VS o Ex) chest pain from ischemia, multiple traumas unless responsive ESI-3= Stable – Possible life threatening, multiple procedures and tests o Must have normal VS o Ex) abdominal pain or gynecologic disorders unless in severe distress, hip fracture in older pt ESI-4= Stable – not life threatening, requires exam and 1 diagnostic test o Ex) close extremity trauma, simple laceration, cystitis ESI-5=Stable- not life threatening, requires exam only o Ex) cold symptoms, minor burn, recheck (wound), prescription refill

Primary Survey   

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Focus on identifying & stabilizing life-threatening conditions What life threatening injury or illness am I dealing with, what do I need to do first to sustain life If uncontrolled external hemorrhage is noted, the usually ABC assessment format may be reprioritized to C (catastrophic) ABC o Apply direct pressure with sterile dressing followed by pressure dressing A - Airway B - Breathing C - Circulation D - Disability E- Exposure

A: Assessment of Airway    

Inspection Auscultation Palpation: palpate face, neck, chest for tenderness, swelling, fractures or subcutaneous emphysema Maintain cervical spine stabilization with airway management.

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Determine LOC by assessing response to verbal and/or painful o AVPU Visual, vocal and airway impairment- priority o Listen for breath sounds, visual chest for rise and fall, palpating pulse o No pulse= begin CPR o Prepare for mechanical ventilation to maintain airway, whether they have a pulse or not o You can find the airway by seeing the gurgling o In facial trauma- consider spinal cord stabilization and palpate for additional injuries Cervical and spine=always think of airway and stabilize spinal cord o There is some level of hypoxia, hypoventilation, hypotension o Risk for injury rise dramatically the presence of head and facial trauma Airway Interventions: Least to most invasive! o Oxygen- 100% nonrebreather o Suction- provide suction with physician is performing the procedure Chin lift/jaw thrust- opens airway (avoid hyperextension of neck) Oral/Nasal airway Intubate- 100% FiO2 until you can figure out what oxygen support the pt needs Cricothyrotomy- procedure involved placing a tube at the cricoid membrane in the throat, est airway and ventilation for pt who cannot be intubated  Done emergently with unstable pt where you cannot get an airway with ET tube  RN prepares for procedure, assist physician in finding the right landmarks, due this by placing pt supine and palpating the trachea, monitor for VS, assess blood loss  Post procedure- make sure cric is in the right place  Dangerous because it’s done close to the innominate artery, you will die if tube goes there  Assist in providing adequate pain medication and sedation if needed  Ensure you have a patent IV, large bore 18g  Suction  Procedural bleeding  S&S of respiratory distress RSI: Rapid-Sequence Intubation o Preferred procedure for securing an unprotected airway o Airway intervention o Use of sedation/anesthesia and paralytic o o o o

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Tip: be sure to give medication in right order. Sedation prior to paralytic https://www.youtube.com/watch?v=kTd7km_jnKw Nurse should have medications prepared Place nonrebreather on pt prior to intubation Suction set up, ready, and on

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Ambu bag set up at bedside with O2 flowing Notify X- rays. CXR is needed to confirm ET placement Have capnography at bedside, placed at end of ET tube to measure end tidal Co2 and confirms you are in the lungs (etCO2 monitor) Assist provider with visualizing the airway by putting pressure on the cricoid membrane

B: Breathing & Ventilation / POST RSI         

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https://www.youtube.com/watch?v=RcPSK1Okbls Inspection: spontaneous or assisted (AMBU BAG), rise and fall of the chest Auscultation: bilateral breath sounds, diminished or absent breath sounds Palpation: chest wall, clavicle, and neck for tenderness, and SQ air Causes: fractured ribs, pneumothorax, penetrating injury, allergic reaction, pulmonary emboli, and asthma attacks S&S: dyspnea, paradoxical or asymmetric chest wall mvmt, decreased or absent breath sounds on the affected side, visible wounds to chest wall, cyanosis, tachycardia, and hypotension Things the nurse should be doing immediately after the artificial airway is placed and while waiting on the radiography team to come and shoot a cxray for tube placement confirmation. This video shows different types of abnormal breathing that can be visualized on inspection. Dependent on your emergency assessment of the patient's chest, they may need procedures such as chest tube placement, needle decompression etc. o Pneumothorax, hemothorax, flail chest- life threatening o Understand what assessments looks like  Notify the HCP for needle decompression Chest Tube: https://www.youtube.com/watch?v=rhN_QgKvTkE o Be sterile as possible in the field o Make sure supplies are prepared for physician o o

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Consider pain meds, sedation, and local anesthesia If able put pt in semi flowers with affected arm behind head (consider there is a lot of blood, deformity, putting arm behind the head slows physician to visualize it more clearly) Monitor for chest tube success: recoil of the chest, positive output in chest tube, improved vital signs

C: Circulation  

Uncontrolled internal or external bleeding places a person at risk for hemorrhagic shock Palpation: accurate representation of BP and perfusion without bedside monitoring o PULSES! o RADIAL/FEMORAL/Carotid  If you can feel a carotid pulse- systolic BP is at least between 60-70 mmHg  Carotid + femoral= systolic BP between 70 and 80

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Radial pulse= systolic BP of at least 80

Inspection: o inspect skin for color, temperature and moisture o Alerted mental status and delayed cap refill (longer than 3 seconds) are common signs of shock Circulation Interventions o Think large volume loss from hypovolemic or hemorrhagic shock, impairment  S&S of shock o Insert two large bore IV’s o Start fluid resuscitation immediately Normal Saline Lactated Ringers Consider intraosseous or central venous access if unable to rapidly obtain venous access Investigate underlying cause Primary goal is to stop the bleeding   

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DELIVER HIGH QUALITY CPR C~A~B         

Start compressions within 10 seconds of identifying cardiac arrest Compress chest at least 2 inches, 30 times on the lower half of the breastbone Compress 2-handed, with one hand on top of the other Compress at a rate of at least 100 compressions per minute Each set of 30 compressions should take 18 seconds or less Allow complete chest recoil after each compression Minimize interruptions in chest compressions to less than 10 seconds CPR ratio is 30 compressions to 2 breaths Ratio stays the same for one-person & two-person CPR

D: Disability       

Brief Neuro Assessment A- Speak to patient, if alert and responsive = Alert V- response to verbal stimuli =Verbal P- response to painful stimuli = Pain U - does not respond to painful stimuli = Unresponsive Decreased LOC, think about the distance the pt is from their normal cognitive abilities GSC scale

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Overall score of 15 for pt at cognitive baseline Overall score of 3 can correlate with death In traumatic setting GCS score of 8 or less indicates need to ET intubation

 Pt is unable to maintain their airway https://www.youtube.com/watch?v=FihnmEx6Rqk Pupils

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Pupils Can tell you a lot about their decline  Injuries regarding possible stroke, seizure, and potential head trauma  Ex)In a car accident there is a coup countercoup injury the friction and shearing caused by injury inhibits clotting cascade and become anti coagulation people may have stroke or seizures because of decreased clotting Use of drugs and alcohol go hand and hand with traumatic and emergency event Assess pupils because it maybe a drug OD, can help guide you to the correct antidote

E: Expose/Environmental 

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Remove clothing o Be mindful of dignity as best you can but you don’t want to miss finding underneath clothes, maintain normal therma KEEP PATIENT WARM Prevent heat loss with warming measures such as warm blanket, warming lights and warm fluids. o Traumatic events induced hypothermia, body vasoconstricts to maintain hemodynamic integrity o Think about hemodynamics as you warm them up

Assessment A -assess for catastrophic external bleeding -assess alertness (AVPU) -assess for respiratory distress -determine airway patency -check for loose teeth or foreign bodies -assess for bleeding, vomitus, or edema

B -assess ventilation -scan chest for signs of breathing -look for paradoxical mvmt of the chest wall during inspiration and expiration -note use of accessory muscles or abdominal muscles -observe and count respiratory rat -note color of nail beds, mucous membranes -auscultate lungs -assess for jugular venous distention and trachea position C -check carotid or femoral pulse -palpate pulse for quality and rate -assess skin color, temp, and moisture -check cap refill

D -Assess LOC by determining response to verbal and/or painful stimuli (GSC) -assess pupils for size, shape, equality, and

Interventions -Control bleeding with direct pressure and pressure dressings -Open airway using jaw- thrust maneuver -Remove or suction any foreign bodies -Insert oropharyngeal or nasopharyngeal airway, tracheostomy -initiate rapid sequence intubation -immobilize c spine using rigid c collar and cervical immobilization devices -give supplemental O2 via appropriate delivery system -ventilate with BVM with 100% O2 if respirations are inadequate or absent -prepare to intubate if severe respiratory distress (agonal breaths) or arrest -have suction available -if absent breath sounds, prepare for needle thoracostomy and chest tube intubation

-if absent pulse, start CPR and ALS measures -if shock symptoms or hypotensive, start 2 large bore (14- 16 g) IVs and start infusion of NS or LR -consider intraosseous or CVA if IV access cannot be rapidly obtained -give blood product if ordered -periodically reassess LOC, mental status, and pupil size and reactivity

reactivity E -Assess full body for determination of additional or related injuries -assess environment

-remove clothing for adequate examination -stabilize any impaled objects Keep pt warm with blankets, warmed IV fluids, overhead lights to prevent heat loss, if appropriate -maintain privacy

Secondary assessment Considered the secondary assessment when pt is table and primary is done and complete F: Full Set of Vital Signs      

Blood Pressure Pulse Rate Respiratory Rate Oxygen Saturation Temperature Pain

G: Give Comfort  

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Pain management Non- pharmacologic o Support and assure family and pt o Make sure they have a clear understanding of what is happening General comfort measures o Reassurance o Repositioning o

Temp control

H: History & Head-to-Toe Assessment        

Ask pt SAMPLE S- symptoms associated with injury or illness A- Allergies M- Medications (current) P- PMH past medical hx L- Last meal (important because they may be going into surgery) E- Event (recall event) Physical: Head-to-toe assessment o Head, neck, and face  Check eyes for extraocular mvmt

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Disconjugate gaze is a sign of neurological damage Battle’ sign may indicate a fracture of the base or posterior part of the skull Raccoon eyes occur with fracture to the base of the frontal part of skull Check ears for blood and CSF Do not block clear drainage from the ear or nose Inspect eyes, ears, nose, and mouth for bleeding, foreign bodies, drainage, pain, deformity, bruising, and lacerations Palpate head for depression of cranial or facial bone, contusions, hematomas, areas of softness, bony crepitus, Assess neck for stiffness, pain in cervical vertebrae, tracheal deviation, distended neck veins, bleeding, edema, difficulty swallowing, bruising, subcutaneous emphysema, bony crepitus

Inspection and palpation of chest will clue the nurse to heart and lung injuries Observe rate, depth, and effort of breathing, including chest wall mvmt and use of accessory muscle  Palpate for bony crepitus and subcutaneous emphysema  Auscultate breath sounds  Obtain 12 lead ECG and CXR Abdomen and flanks  MVC and assaults can cause blunt trauma.  Penetrating trauma tends to injure specific organs  Stabilize but do not remove any impaled objects  Perform FAST assessment to identify blood in the peritoneal space and assess cardiac function. Get CT if suspected retroperitoneal bleed  Look for symmetry of abdominal wall and bony structure  Auscultate for bowel sounds  Palpate for masses, guarding, femoral pulses  Note type and location of pain, rigidity, or distention of abdomen Pelvis and perineum  Inspect and gently palpate the pelvis, do not rock the pelvis  Pain may indicate pelvic fracture and the need for imaging  Assess for bladder distention, hematuria, dysuria, or inability to void  Rectal exam to check for blood, prostate gland problems, and loss of sphincter tone Extremities  Assess upper and lower extremities for point tenderness, crepitus, and deformities  Splint extremities  Check pulses before and after mvmt or splinting of extremity  A pulseless extremity is a time critical emergency

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Immobilize and elevate injured extremities and apply ice packs Abx are given for open fractures to prevent infection

I: Inspect Posterior Surfaces 

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ALWAYS inspect posterior surface of patient o ALWAYS log roll pt, maintain C spine protection with at least two nurses o Palpate vertebral column for crepitus, pain, or abnormal palpation outside the linear C spin o Look for entrance or exit wounds, lacerations, bleeding, consider blood loss underneath pt o Check rectum- done digitally, aid in diagnosis in potential lower intestinal, urethral, or spinal cord injuries Trauma o Wound or injury inflicted on a body  Can be from another person or object  From a mechanism in which the body cannot protect itself o Consider Forensic Evidence- especially in situations where it seems to be criminal or inflicted with ill intent  Ex) covering hands of gunshot victims so an investigation to check for residue (rule in or out suicide or a secondary party being involved)  Cover hands with paper bags  Keep clothing in separate bags, each piece of clothing in a separate paper bag. Pt info should be on bag  In clothing is wet, hang it up to dry  If pt can talk, for documentation always use quotations

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Priority Management o Establish Airway and Ventilation o Control Hemorrhage and other underlying causes o o o o o o

 Consider immediate resuscitation Prevent and Treat Hypovolemic Shock Assess for Head and Neck Injuries  Stabilize the head and neck Evaluate for Other Injuries Splint Fractures and Reassess Pulses and Neurovascular Status  Continually check neuro status, can change quickly Perform more thorough assessment, and diagnostic studies  Done in secondary survey Assess airway and volume loss

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Evaluate for tetanus prophylaxis  Major complication of open injuries and wounds Finally consider transport to more appropriate level of care

Types of Injuries 

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Intra-Abdominal Injuries o Penetrating - GSW, Stab wounds o Blunt – MVAs, Falls, Blows, Explosions  Look for guarding  If pt is able and guarding the right shoulder= potential issue with liver, liver laceration is not uncommon in fender bender  left arm= potential issue with heart, (seen with airbags) cardiac contusion  Left shoulder= consider problem with spleen  Internal Bleeding  Intraperitoneal Injury  Genitourinary Crushing Injuries / Fractures Fast Exam o Use in trauma situations and trauma bay o Assess for free fluid, primarily blood loss, and usually indicative of blunt force trauma o Focus assessment with sonography (US) limited beside US, very quickly detects for free intraabdominal fluid or cardiac complications o Very quick US and assess areas for free fluid or cardiac dysfunction

o Gerontologic Considerations: Emergency Care  

Elderly are at high risk for injury—primarily from falls. o Many are on blood thinners Important to determine what caused the fall o In secondary assessment determine underlying causes and eliminate risk in the home

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When assessing a pt who has fallen, determine whether the physical findings may have caused the fall or are due to the fall itself Generalized weakness Environmental hazards Syncope Orthostatic hypotension Anticoagulation 

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In the gerontologic population the brain has atrophied so their body can absorb the blood for longer so bruising may not show up until later

Priority Practice o 1. Client complaining of muscle aches, headache, malaise o 2. Client who twisted ankle after fall o 3. Client with minor lacerations on finger while cutting an onion o 4. Client with chest pain who states just ate o 4 is priority  Assess respiratory status, ECG, ensure patent IV Priority pra...