Emergency Nursing Principles & Management

ED Environment (5)

1. Rapid change

2. Multispeciality care

3. Crowded & noisy

4. Crucial communication - prehospital helicopter personnel

5. Complex age & demographic range of patients

Reasons People Seek ER Care (7)

1. Pain (MOST common)

2. Injuries (especially falls)

3. Abd pain

4. Chest pain

5. Difficulty breathing

6. Headache

7. Fever

Interdisciplinary Team Members (5)

1. Prehospital Care Providers - EMTs, Paramedics

2. Emergency Medicine Physician

3. NPs & PAs

4. Support staff

5. Nurses - Forensic nurse examiners (rape, child abuse, & DV victims), Psychiatric crisis nurse team

Staff & Patient Safety Considerations (4)

1. Standard information hand-off communication

2. Patient identification

3. Injury prevention for patients & staff

4. Risk for errors & adverse events

ED Nurse Skills (4)

1. Assessment - Must be quick & accurate

2. Priority setting & multi-tasking

3. Assists ER physicians with procedures - Procedure set-up, patient prep & teaching, & post procedure care

4. Communication

Training & Certification (2)

• ER Training - BLS, ACLS (Advanced Cardiac Life Support), PALS (Pediatric Advanced Life Support), ENPC (Emergency Nursing Pediatric Course), & TNCC (Trauma Nursing Core Course)

• Certified Emergency Nurse (CEN) - Validates core emergency nursing knowledge base, national exam.

Triage (4)

1. Sorts/classifies patients into priority levels according to illness or injury severity

2. Highest acuity needs quickest evaluation, treatment, & prioritized resource utilization

3. Applied consistently by nurses endorsed by physicians

4. ESI & Canadian Triage Acuity Scale (CTAS) most reliable

Emergency Severity Index (ESI) Triage Levels (5)

• Level 1 Immediate (Life threatening) - Needs life saving care right now; Cardiac arrest, not breathing, severe trauma

• Level 2 Emergent (high risk) - Very sick & can get worse fast; Chest pain, stroke symptoms, severe SOB

• Level 3 Urgent - Stable but needs multiple tests or treatments; ABD pain needing labs & imaging

• Level 4 Less Urgent - Stable & needs one test or treatment; Simple fracture needing an xray

• Level 5 Not Urgent - Stable & needs no tests; Med refill & minor rash

Care of the ED Patient (6)

1. Patients have variety of health care needs

2. Cultural considerations

3. Care of patients with mental illness

4. Disposition & discharge needs

5. Case management

6. Patient & Family Teaching

Death in the ED (5)

1. Sudden/Unexpected Death

2. Family presence during resuscitation

3. Special circumstances when medical examiner case involved

4. Dealing with family members in crisis

5. ED Personnel dealing with death

Mechanism of Injury (MOI) (4)

• Manner in which a traumatic event occur

• Blunt trauma

• Acceleration/Deceleration Forces - Sudden increase/decrease in speed causing trauma

• Penetrating Trauma

Primary Survey

A rapid assessment of life-threatening conditions.

Completed systematically so life-threatening conditions are not missed.

Primary Survey & Resuscitation Interventions (7)

1. Scene Safety - Don PPE (standard precautions)

2. Primary survey organizes order of approach to patient by ABCDE method of triage as a guide

3. A - Airway/cervical spine

4. B - Breathing

5. C - Circulation - Shock or hemorrhage; Compromised circulation

6. D - Disability - AVPU, Glasgow; Determines LOC

7. E - Exposure - Remove clothing to assess any injuries

Assessment to Determine LOC (2)

AVPU - Alert, Responsive to voice, Responsive to pain, Unresponsive

Glasgow Coma Scale - Eye opening, verbal response, motor response

Secondary Survey

Performed after the priorities are completed

Secondary Survey & Resuscitation Interventions (7)

1. History & Comprehensive physical assessment

2. Diagnostic & lab testing review

3. Provide wound care

4. Insert drainage tubes

5. Provide comfort & emotional support to client & family

6. Crisis intervention

7. Appropriate referrals if needed

Disposition (4)

• What happens to the patient after evaluation/treatment—where they go next or what happens to them.

• Depends on nature of injury & facility’s resource capability

• Transport immediately to OR or interventional radiology suite

• Admit to trauma, CCU, step-down unit, or surgical floor for continued care

• Transfer to facility with higher level of care

Considerations for Older Adults (4)

• Complicated medical histories

• Comorbid conditions that make care difficult

• Memory impairment makes for difficult history intake

• May have difficult discharge needs & must consider safety issues after discharge

Cultural Awareness (4)

• Customize discharge instruction to address patient needs

• Consider patient’s reading level, primary language, & visual acuity

• Education materials/instructions at 6th grade reading levels

• Give materials in preferred language, use interpretors as needed