Sr . no Specific Objectives Dura tion Contents TEACHING LEARNING ACTIVITY A V AIDS BLACKBOARD ACTIVITY EVALUATION 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
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Sr. no
Specific Objectives
Duration
Contents TEACHING LEARNING ACTIVITY
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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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.
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.
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