1. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 10 Concepts of Emergency and Trauma Nursing

2. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Learning Outcomes 1. Describe the emergency department (ED) environment, including vulnerable populations and interdisciplinary team members. 2. Identify the roles and responsibilities of the health care team members in the ED. 3. Plan and implement best practices to maintain staff and patient safety in the ED. 4. Explain selected core competencies that nurses need to function in the ED.

3. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Learning Outcomes (continued) 5. Triage patients in the ED to prioritize the order of care delivery. 6. Prioritize resuscitation interventions based on the primary survey of the injured patient. 7. Describe the general process of admission through disposition of a patient in the ED.

4. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. ED Environment Characterized by: Rapid change Multispecialty care Crowded, noisy conditions Crucial communications with ambulance staff, helicopter personnel Complex age and demographic range of patients

5. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Common Reasons People Seek ED Care Abdominal pain Chest pains Breathing difficulty Injuries (especially falls) Headache Fever Pain (most common)

6. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Special Nursing Teams Forensic nurse examiners (for victims of rape, child abuse, domestic violence) Psychiatric crisis nurse team

7. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Interdisciplinary Team Members Prehospital care providers Emergency medical technicians (EMTs) Paramedics Emergency medicine physician Support staff Inpatient unit staff

8. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Prehospital Care Provider

9. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. SBAR- Approach to hand-off communication S = Situation B = Brief medical hx (Background) A = Assessment (Is the patient contagious?) (What interventions did you do?) R = Response

10. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Staff & Patient Safety Considerations Chart 10-1 Correct patient identification Injury prevention for patients Decrease risk for errors and adverse events Injury prevention for staff

11. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Scope of Emergency Nursing Practice Assessment Prioritizing/critical decision-making Multi-tasking Critical care equipment Assisting with procedures Communication

12. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Training & Certification Basic Life Support (BLS) Advanced Cardiac Life Support (ACLS) Pediatric Advanced Life Support (PALS) Certified Emergency Nurse (CEN)

13. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Triage Sorts/classifies patients into priority levels according to illness or injury severity Highest acuity needs get soonest evaluation, treatment, prioritized resource utilization

14. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Three Triage System and Examples Table 10-2 Emergent Client has a life threatening situation or may lose a limb Urgent Client needs quick treatment but the situation is not immediately life threatening Non-urgent Client could wait several hours if needed without fear of deterioration

15. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Triage (cont’d)- Examples Emergent Respiratory distress, chest pain, hemorrhage Urgent Abdominal pain, fractures, soft tissue injuries Nonurgent Skin rash, strains/sprains, “colds”

16. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Death in the ED “Expected” death “Sudden/unexpected” death Family presence during resuscitation Caring with family members in crisis Bereavement committees

17. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Trauma Nursing Principles Trauma= bodily injury Can be intentional Can be unintentional Trauma centers (Level I to Level IV) Trauma systems

18. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Mechanism of Injury (MOI) Manner in which traumatic event occurred: Blunt trauma Acceleration- deceleration forces Penetrating trauma

19. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Primary Survey and Resuscitation Interventions- STUDY Table 10-4 Primary survey organizes order of approach to patient by: (A) Airway/cervical spine (B) Breathing (C) Circulation (D) Disability (E) Exposure

20. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Secondary Survey and Resuscitation Interventions Secondary Survey=Comprehensive head-to-toe assessment identifies other injuries/issues that must be managed or may impact course of treatment Gastric tubes Urinary catheters Diagnostic studies

21. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Disposition Depends on nature of injury, facility’s resource capability: Transport immediately to OR or interventional radiology suite Admit to trauma critical care unit, step- down unit, or surgical floor for continued care Transfer to facility with higher level of care

22. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question 1 The emergency nurse is working in the triage area. Which of these four patients should the nurse evaluate first? A. Child who has a broken arm, with the bone protruding from the wrist B. 62-year-old woman who is reporting severe chest pain, nausea, dizziness, and profuse sweating C. 22-year-old man who is bent over in pain and believes he has kidney stones D. 72-year-old woman who has a productive cough and a temperature of 101.6  F

23. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Answer: B Rationale: Based on the information provided, the patient experiencing crushing substernal chest pain, shortness of breath, and diaphoresis would be classified as emergent and triaged immediately to a treatment room within the ED. The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. The urgent triage category indicates that the patient should be treated quickly but that an immediate threat to life does not exist at the moment. Examples of patients who typically fall into the urgent category are those with a new onset of pneumonia (as long as respiratory failure does not appear imminent), renal colic, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature greater than 101  F (38.3  C).

24. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question 2 A woman has just been admitted to an available ED bed. She had reported feeling dizzy. As the nurse asks the patient her name, she suddenly falls unconscious. What is the first thing the nurse should do? A. Ask the husband to leave the room. B. Evaluate the patient’s level of consciousness. C. Establish a patent airway by positioning, suctioning, and administering oxygen, as needed. D. Take her blood pressure and pulse.

25. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Answer: C Rationale: The primary survey organizes the approach to the patient so that immediate threats to life are rapidly identified and effectively managed. The primary survey is based on a standard “ABC” mnemonic with a “D” and “E” added for trauma patients: airway/cervical spine (A), breathing (B), circulation (C), disability (D), and exposure (E). The highest priority intervention is to establish a patent airway.

26. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question 3 A woman is admitted to the ED for complications from a reported fall in her kitchen. You notice multiple bruises around her face and upper arms. You can tell that she is upset and has been crying, but she does not offer details about what happened. Her husband repeats that she fell in the kitchen. He agrees to leave the room for your examination. Which action should you take next? A. Ask her, “Is everything okay between you and your husband?” B. Complete the physical examination. C. After the examination, make an anonymous call to social services to report suspected domestic violence. D. Ask the ED’s forensic nurse examiner to see the patient.

27. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Answer: D Rationale: Many EDs have specialized teams that deal with high-risk populations of patients. Forensic nurse examiners (RN-FNEs) are educated to obtain patient histories, collect forensic evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence—also known as intimate partner violence (IPV) (Scales et al., 2007). They are trained to recognize evidence of abuse and to intervene on the patient’s behalf. Forensic nurses who specialize in helping victims of sexual assault are called sexual assault nurse examiners (SANE) or sexual assault forensic nurses (SAFE). Interventions performed by forensic nurses may include providing information about developing a safety plan or how to escape a violent relationship. Forensic nurse examiners document injuries and collect physical and photographic evidence. They may also provide testimony in court as to what was observed during the examination and information about the type of care provided.