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Emergency Nursing & Mass Casualty Priorities

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Presentation on theme: "Emergency Nursing & Mass Casualty Priorities"— Presentation transcript:

1 Emergency Nursing & Mass Casualty Priorities
Keith Rischer RN, MA, CEN ED visits incr 14% from but # ED’s decr. From 4005 to 3934 41 million uninsured…ED primary care provider Most common chief c/o…CP, abd pain, HA, fever Those over 75 generate the highest ED visit rates Frequent fliers…manipulate the system to their advantage…drug seeking or other low acuity c/o…use EMS for clinic c/o EMTALA-cannot turn anyone away or face losing your medicare reimbursement same with EMS 3/25/2017

2 Todays Objectives Identify the core competencies needed to function in emergency setting Explain the different roles of the interdisciplinary team Describe the triage process Triage different clients into emergent, urgent, and nonurgent categories Identify nursing assessment “red flags”regarding chief complaint Identify the role of the primary & secondary survey Contrast triage process under usual ED context w/triage in mass casualty 3/25/2017

3 Emergency Department Environment
Characterized by: Rapid change Med errors Multispecialty care Crowded, noisy conditions Hostile behavior Staff safety Crucial communications EMS Complex age and demographic range of clients 3/25/2017

4 Frequent Fliers…Problem
ED visits increased 26% to 114,000,000 annually in US FF represent small %, consume disproportionate amt. of health care dollars Contributes to overcrowding 5% of all ED pts. 1/3 ED visits non-urgent-could be provided in other settings Defined-6 or more ED visits annually 3/25/2017

5 Frequent Fliers…Demographics
35 yr old Caucasian female Single, unemployed Has primary MD and public/private health insurance Chronic medical conditions w/pain of same type the most common CC Non-narcotic approaches to pain utilized ED visits decr. From 19 to 7 annually 3/25/2017

6 Interdisciplinary Team Members
Prehospital care providers Paramedic Emergency Medical Technician (EMT) Emergency medicine physician Registered Nurse BLS ACLS PALS TNCC Certification in Emergency Nursing (CEN) Support staff Emergency Tech Unit Support Sexual assault nurse examiners Psychiatric Crisis Inpatient nursing staff 3/25/2017

7 Triage Brief clinical assessment to determine time, order, and sequence clients are seen Quickly identify emergent/life threatening conditions as well as SUBTLE manifestations highest acuity needs receive the soonest evaluation, treatment, and prioritized resource utilization Triage nurse in the emergency care system performs rapid assessment to determine triage priority by category: Emergent triage Urgent triage Nonurgent triage TRIGE-def…TO SORT OUT Original context battlefield health care 3/25/2017

8 Triage Interview Assess carefully “What brought you to the ER today?”
Use all senses Visual Smell Auditory Tactile/touch Intuition Assess carefully…NEVER ASSUME IS NOT SICK BECAUSE THEY DO NOT LOOK LIKE IT NEED TO SORT OUT DRAMA 3/25/2017

9 ED Assessment: Airway/Breathing Red Flags
Obvious resp. distress Tachypnea O2 sats <90% Hx of COPD, asthma or croup Recent surgery or immobility Drooling-SOB Stridor or barky cough 3/25/2017

10 ED Assessment:Chest Pain Red Flags
Male >30 yrs…>35 yrs female or post menopause High risk factors…hx CAD, DM, high cholesterol, HTN Chest pain Cardiac Quality Radiation Severity timing Non-cardiac High risk factors…hx CAD, DM, high cholesterol, HTN DM and HTN have highest correlation to AMI 3/25/2017

11 ED Assessment : Women & CAD
#1 killer of women…more than #2-14 combined Develop 10 yrs later than men on avg. Protective effects estrogen Atypical presentations Mortality rate 2x higher than men Unrecognized sx/atypical presentation Less likely to be dx w/AMI Do not receive early & aggressive tx 3/25/2017

12 ED Assessment: Headache Red Flags
Sudden onset-severe Syncopal or neuro deficits present HA w/fever Recent head trauma Coumadin Distinctly different from previous hx “worst headache I’ve ever had” 3/25/2017

13 ED Assessment:Abdominal Pain Red Flags
Blood in emesis or stool Persistent N&V &D >18 hours older than 6 yrs >12 hours if less than 6 yrs Sudden AAA Bowel obstruction Renal calculi Chole/pancreatitis Gradual Appe Constipation UTI Palpation or any body movement worsens Sudden onset vs. gradual SUDDEN…AAA-BOWEL OBSTRUCTION 3/25/2017

14 ED Assessment: Pearls Across the Lifespan
Trauma MECHANISM OF INJURY Pediatric Child abuse Larger tongue/smaller trachea Dehydration-lips/mucous membranes/no tears Temp >100.4 in child <12 weeks Elderly Elder abuse/neglect Use other family members to clarify CC Slow down to sort out Hypothermia-sepsis Atypical CP 3/25/2017

15 Triage How do you classify & prioritize the following?
28 yr male w/laceration-bleeding controlled 22 yr female w/lower abd pain & heavy vaginal bleeding 22 yr female w/lower gradual abd pain 8/10 only 45yr female w/CP last 2 hours-hx DMII 20 yr male w/CP-worsens w/deep insp. 78 yr female w/HA & brief syncopal episode 82 yr male w/abd pain-distended 10/10 3/25/2017

16 Primary & Secondary Survey
(A) Airway/cervical spine (B) Breathing (C) Circulation (D) Disability Glascow coma scale AVPU…LOC assessment (E) Exposure Secondary The primary survey organizes the order of approach to the client by mnemonic device: SECONDARY SURVEY:Comprehensive head-to-toe assessment to identify other injuries or medical issues that need to be managed or that impact the course of treatment FOCUSED ASSESSMENT-NOT COMPLETE HEAD TO TOE 3/25/2017

17 Care of the Emergency Department Client
Nursing assessment Triage Chief complaint VS PMH Primary RN once in room Primary/secondary assessment Initiate standing orders Delegate to ED tech prn Physician assessment Disposition Client and family health teaching STANDING ORDERS CP-SOB DRAW RAINBOW LABS CXR O2 to maintain O2 sats >92% SL ASA 325 mg asthma O2 Peak flows Alb neb tx Abd pain-vag bleeding Draw rainbow labs Urine pg UA 3/25/2017


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