ANS: A, C, D, F Show
The nurse is assessing arterial blood gases (ABGs). The client with which ABG reading requires the nurse's immediate attention? Sets found in the same folderemergency care basics -its a growing need the emergency department environment of care -rapid change is the standard demographic and vulnerable populations -homeless most common causes of care -abdominal pain special nursing teams FORENSIC NURSE EXAMINERS; -interventions by these people is collected and used for evidence PSYCHIATRIC CRISIS NURSE TEAM; interdisciplinary team collaboration -a
team approach must be used pre hospital care providers -first caregivers that someone sees before they are transported to a hospital PARAMEDICS; -this pre hospital support is imperative. emergency medicine physician -specialized education the ED nurse -must communicate with every aspect of the health team -must give an extremely detailed report to the inpatient unit if the patient is going to stay -SBAR method is preferred staff safety -transmission of disease -usually a cop or security in the ED ACTION ALERT -be alert for volatile situations of aggressive or violent tendencies patient safety common patient safety issues are; patient identification -identification bracelet at point of entry -provide a ID bracelet for every patient
fall prevention -start with identifying people at risk -keep rails up on a strecher protecting skin integrity -assess the skin potential of errors or adverse events -get as much information as possible -obtain thorough history hospital acquired infection -older adults in particular for UTI or respiratory infections core competencies -skilled in assessment, priority setting, and clinical decision making, multitasking, communication is a big one -sound knowledge base is essential -assessment is the foundation -priority settings is another big one -must understand legalities to things like abuse and violence -nurse often initiates collaborative protocols for lifesaving interventions like cardiac monitoring and o2 therapy or IV catheters core competencies cont. -must be very good at multitasking common ED procedures include -the nurse collaborates and assists a physician with a number of procedures -all part of the emergency nursing practice -communication is another large part of a ED nurse training and certification
-two general types of certification are referred to in emergency nursing practice -certification marks successful completions of a course of study -advanced concepts in cardiac monitoring TRAINING AND CERTIFICATIONS NEEDED FOR ED NURSE basic life support; advanced cardiac life support; certified emergency nurse; triage -ED triage is an organized system for sorting or classifying patient priority levels depending on illness or injury severity -highest acuity needs receive the quickest evaluation, treatment, and resources (ct scan) -lower level acuity issue may wait longer in the ED because people with more severe issues move "ahead of line" -answer questions of i've been here for..." -RN is typically the person assigned to perform triage function in most
hospitals. emergent, urgent, nonurgent categories -many triage systems can be used by a hospital emergent example; urgent example; nonurgent; TIERS AND EXAMPLES CHART emergent (life is threatened); urgent (treatment needed, currently safe); nonurgent (could wait hours); other multi tiered models -four and five stages
exist THE ER NURSE IS GIVEN 5 PATIENTS WAITING FOR ORDERS TO BE IMPLEMENTED. WHICH CLIENT DO YOU SEE FIRST? -60 year old man waiting to go to the operating room for an emergency appendectomy. -someone sleeping your
fine disposition -at the conclusion of the assessment, physician must make a decision regarding disposition (where should you go after being discharged from the ED) -admit? go home? follow up? -decision may be less
clear case management -RN case managers who intervene to arrange appropriate referral and follow up -desired outcome of this is to keep people out of the hospital and keep them educated on their disease. (COPD, kidneys, heart) -ED case manager is also used for disposition for homeless people, safe environment for domestic violence patient and family education -health teaching is a key
component death in the emergency department -can be expected by families
-one or two family members may be given the opportunity to be present during lifesaving procedures. -if the patient dies before family arrives, ED may prepared the body and room for viewing by the family. -forensic investigation may be needed and IV lines and indwelling tubes do not get removed due to evidence. -use
words like death or died. -crisis staff may be needed (social workers or psych nurses) -bereavement committees that focus on meeting the needs of grieving families the impact of homelessness -636k
people in 2011 -crisis or persistent poverty -ED is a safe place with food, shelter, and care -avoid stereotyping -watch for potential violent behavior trauma nursing principles -trauma refers to bodily injury. -intentional (shot, stabbed) trauma centers and trauma systems -trauma
centers have their roots in military medicine trauma centers -not all EDs that have an around the clock emergency services are considered trauma centers levels of trauma LEVEL 1; LEVEL 2; LEVEL 3; LEVEL 4; LEVELS AND FUNCTIONS CHART 1; 2; 3; 4; mechanism of injury (MOI) -describes how the injury occurred -most common injury producing mechanisms are blunt trauma and penetrating trauma BLUNT TRAUMA; PENETRATING TRAUMA; primary survey and resuscitation interventions -scene safety is basic tenet of er care A (airway) -this is the highest priority B (breathing) -this
determines weather ventilatory efforts are effective or not. -if CPR is needed, mech vent is disconnected and manually ventilated with BVM. CRITICAL RESCUE -clear airway of secretions
or debris C (circulation) -when effective ventilation is ensured, priority shifts to circulation external hemorrhage; internal hemorrhage; -antecubital area is preferred for IV -RL and normal saline are fluids of choice for resuscitation -anticipate the need for blood for someone with an active hemorrhage D (disability) -rapid baseline assessment of neuro status. AVPU; -another way to determine LOC is with GCS E (exposure) -remove all clothing for a complete
assessment -handle evidence appropriately (policy) secondary survey and resuscitation intervention -insertion of gastric tube for decompression of GI tract to prevent vomit and aspiration insertion of catheter for output measurements -secondary survey is done to identify other injuries or medical issues. TRAUMA CLIENT BROUGHT TO THE ER POST A MVA. SEVERE INJURIES ARE PRESENT. WHAT ACTION DO YOU DO FIRST? -start 2 large bore IVs and run normal saline -stabilize the spine and airway. -----------------------CHAPTER ENDS---------------------- -------------------EVOLVE BEGINS---------------- What is the nurse's first step when caring for any client in an emergency? Establishing a patent airway. Splinting fractures. Dressing wounds. Evaluating the level of consciousness. Issues identified in the primary survey, an organized system to rapidly identify and effectively manage immediate threats to life, are managed first when caring for a client in the emergency department (ED). The primary survey includes airway, breathing, circulation, disability, and exposure. Therefore, establishing a patent airway is the priority for the client. Splinting fractures and dressing wounds are addressed after evaluating the consciousness level of the client. The nurse in the emergency department is often required to care for clients from various cultural and language backgrounds. What belief comes in the way of caring for a Jehovah's Witness client? Tendency to be very family-oriented Inability to converse in a language spoken by the staff Dislike of their bodies being exposed Refusal of blood transfusions Jehovah's Witness clients do not accept blood transfusions; this belief can affect delivery of care. Some Mexican-Americans tend to be very family-oriented; however, this may not be a barrier for health care. If a client cannot converse in a language spoken by the staff, dedicated interpreters can help to communicate with the client either through telephone or in person. Clients from the Middle East and some Mexican-American clients may be modest and not like their bodies to be exposed; the nurse should take adequate care to maintain the privacy of these clients. The triage nurse is assessing the acuity level of clients rushed to the emergency department. What sign or symptom reported by the client prompts the nurse to classify the client as emergent? Chest pain with diaphoresis Severe abdominal pain Multiple soft tissue injuries Strains and sprains The client having chest pain with diaphoresis should be classified as emergent. The "emergent" category indicates that the client has a condition that poses immediate threat to life or limb. The client with severe abdominal pain and multiple soft tissue injuries are classified as "urgent" indicating that the client needs to be treated quickly but an immediate threat to life does not exist at the moment. A client with strains and sprains is classified as "nonurgent" indicating that the client could wait for several hours without a significant risk for deterioration. Test-Taking Tip: Pace yourself during the testing period and work as accurately as possible. Do not be pressured into finishing early. Do not rush! Students who achieve higher scores on examinations are typically those who use their time judiciously. Who is said to be the gatekeeper in the emergency care system? Physician Physician assistant (PA) Triage nurse Nurse practitioner (NP) The triage nurse is a registered nurse (RN) and is said to be the gatekeeper in the emergency care system because the triage nurse is normally assigned to perform the triage function in the emergency department. The triage nurse may seek the input of an emergency physician, NP, or PA to help establish the acuity level if the client's presentation is highly unusual. The forensic nurse examiner is assessing a client who is a victim of intimate partner violence (IPV). What interventions does the nurse perform for this client? Document injuries and collect photographic evidence. Offer basic life support interventions and wound care Perform advanced airway management and intubation. Evaluate emotional behavior and admit the client to a psychiatric facility. The forensic nurse examiner documents injuries and collects photographic evidence. Emergency medical technicians offer basic life support interventions and wound care. Paramedics provide advanced life support system such as advanced airway management and intubation. The psychiatric crisis nurse team evaluates emotional behavior and admits the client to a psychiatric facility if needed. Which protective gear is most important when caring for clients with tuberculosis or other airborne pathogens? Surgical cap Impervious cover gown Eye protection Powered air-purifying respirator (PAPR) The nurse uses a PAPR or a specially fitted face mask when caring for a client with airborne pathogens. These clients are preferably placed in a negative pressure room if available. When there is a high risk of contamination from blood and body fluids, other safety precautions may be used. These include use of a surgical cap, an impervious cover gown, and eye protection. How is an unconscious male client who is brought to the emergency department (ED) eventually identified? The family is asked to provide details about the client. The client is provided a "John Doe" identification tag. Identification is made after the client regains consciousness. The client is identified by the date and time of arrival to the hospital. Hospitals commonly use a "Jane/John Doe" identification system for clients with unknown identity and those with emergent conditions. All clients are issued an identity bracelet at the point of entry to the ED. The nurse does not wait until the family arrives for details or until the client regains consciousness. The client is not identified by the date and time of arrival to the hospital. Other appropriate identifiers include date of birth, agency identification number, home telephone number or address, and/or Social Security number. How does the nurse ensure a patent airway for a client with significantly impaired consciousness? Apply a nasal cannula. Apply a non-rebreather mask. Provide bag-valve-mask (BVM) ventilation. Provide an endotracheal tube and mechanical ventilation.@@@ The client with significantly impaired consciousness is provided an endotracheal tube and mechanical ventilation. A nasal cannula and non-rebreather mask is used for a client who is able to breathe spontaneously. Bag-valve-mask (BVM) ventilation with the appropriate airway adjunct and a 100% oxygen source is indicated for a client who needs ventilatory assistance during resuscitation. What are the duties of the nurse case manager in the emergency department (ED)? Obtain and record the client health history. Provide discharge teaching. Coordinate the triage process with the triage nurse. Arrange appropriate referrals for the client. The nurse case manager in the ED arranges for appropriate referrals and follow-up for the client. The emergency nurse obtains and records the client history. The nurse provides discharge teaching to the client and client's family. The primary healthcare provider and assistant may coordinate the triage process with the triage nurse.
A client with stab wounds to the abdomen is rushed to a Level III trauma center. What care does the nurse provide for the client in this facility? Stabilize and arrange to transfer the client to a Level I trauma center. Give first aid and transfer the client to the community hospital. Provide life support and transfer the client to a Level IV trauma center. Provide the full gamut of health care at the trauma center. A Level III trauma center would be able to stabilize this client and arrange to transfer the client to a Level I trauma center. Level III trauma centers are usually found in smaller, rural hospitals and are not equipped to provide complete care for clients with traumatic injuries. A community hospital may not be able to provide further care, so there is no need to transfer the client to such a facility. The client would not be transferred to a Level IV trauma center as they are located in remote areas and do not have the capabilities to care for this client till complete recovery. Only a Level I trauma center can provide this client with the full gamut of health care. The provider is planning to discharge a client home. The nurse suspects domestic violence as the cause of injury, although the client denies this. What is the best course of action for the nurse to take? Call the police. Consult with Social Services. Discharge the client as instructed. Instruct the client to go to a safe place. If discharge home is not deemed safe, the client may be admitted to the hospital until resources can be organized to provide a safe environment. Social workers or case managers are consulted to investigate resource needs and plan accordingly. Calling the police is not an appropriate response. Letting the client go home could place the client in danger. The client may not have a safe place to go. -------------------------EVOLVE ENDS---------------------- --------------------SLIDES BEGIN------------------ In which order should clients receive care based on triage tag color quizlet?Red-tagged clients have major injuries, black-tagged clients are expected and allowed to die, and yellow-tagged clients have major injuries.
Which of the following is a triage tag color you would allocate for a wounded patient who is unable to walk has absent respiration even after repositioning the airway?The wounded victim is unable to walk, respiratory rate is absent and when airway is repositioned breathing is still absent. The wounded victim is assigned what tag color? The answer is D: Black.
Which statement below is correct about the red triage tag color in regard to a disaster situation?The answer is C: Red. The red tag indicates the patient must be seen first because they have life-threatening injuries, but could survive if treated quickly.
Which items should the nurse plan to include in disaster preparedness?In an external disaster, many people may be brought to the emergency department for treatment. The initial nursing action must be to activate the disaster plan.. Flashlight.. Supply of batteries.. Battery-operated radio.. Extra pair of eyeglasses.. 4-week supply of water.. |
