EMERGENCY NURSING
Shared by: Michael P. Tuyay, RN, LPT, MASE
The Challenges of ED Care
• Emergency nursing is one of the most challenging
specialties in nursing. It requires nurses to manage
ambiguity and rapid changes in pace and intensity of
work, and to have a knowledge of a significant number
of clinical presentations, diseases, and conditions. The
emergency nurse must also be able to relate to, and
have an understanding of, all ages, from the very
young child to the elderly. Emergency nursing is not
for the faint-hearted!
• 1/3 of hospital care begins in the emergency
department.
• The majority of ED patients require immediate care.
GOLDEN RULES OF EMERGENCY NURSING
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An emergency is an emergency. It is only not an emergency in retrospect!
There is no such thing as a ‘minor’ injury. Behind any so-called ‘minor’ presentation,
there may be a ‘major’ one masquerading.
Remember that what looks trivial to you may have significant ramifications for the
patient.
Do not forget the fundamentals—communication and observation.
Always introduce yourself (‘Hello, my name is … ’).
Monitors are an adjunct—nurse the patient, not the monitor.
‘If you don’t like the patient, spend twice as long with them’—that way you will minimize
mistakes.
‘There is no such thing as a poor historian’—it is probably your inability to elicit the
history.
A fall is only a fall after a collapse has been ruled out.
Remember that what may be a common injury or illness to you may be a first for the
patient and carers.
Have a plan for the worst possible scenario—anything less is a bonus!
Expect the unexpected.
If the patient says they feel as if they are going to die, believe them and do something
about it.
Common things are common, but they can still kill you—you can bleed to death from
your nose or from a large scalp laceration.
GOLDEN RULES OF EMERGENCY NURSING
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The patient is not drunk until they have experienced the hangover—do not be misled
by the smell of alcohol.
In a woman of childbearing age with abdominal pain, actively rule out an ectopic
pregnancy.
In all unwell patients, Don’t Ever Forget Glucose (DEFG).
When caring for children, toys and distraction are essential tools.
Do not attribute hyperventilation to hysteria until an underlying pathology has been
ruled out.
Do not dismiss or trivialize the frequent attender. They may have an underlying
illness.
Ensure that patients re-presenting with the same complaint are seen by someone
senior.
Make sure you are competent to use the equipment around you. You cannot always
rely on someone else to troubleshoot.
If you have a ‘quiet’ moment, use it to familiarize yourself with the latest guidelines
and procedures.
Enjoy what you do. Although it might not always feel like it, it is a privilege to be part
of people’s lives at a time of crisis.
FIVE-LEVEL EMERGENCY
SEVERITY INDEX
Primary and Secondary Surveys
• It is important to perform a Primary and
Secondary survey.
• Primary Survey (make sure you are safe before you treat)
– Detect and treat Life Threatening conditions
– “Treat as you go”
– ABCDE’s
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“A”
“B”
“C”
“D”
“E”
Airway
Breathing
Circulation
Disability
Expose
“A”IRWAY
• An obstructed airway may quickly
lead to respiratory arrest and death.
• Assess responsiveness and, if
necessary, open the airway.
• Assessed while maintaining cervical
spine
• Signs and symptoms of compromised
airway
• Jaw Thrust Maneuver
“B”REATHING
• Respiratory arrest will quickly lead
to cardiac arrest.
• Assess breathing,
and, if necessary, provide rescue
breathing.
• Look for and treat
conditions that may compromise
breathing, such as penetrating trauma to
the chest.
“C”IRCULATION
• If
the
patient’s
heart
has
stopped,
blood and oxygen are not being sent to the brain.
• Irreversible changes will begin to occur in the brain in 4 to
6 minutes; cell death will usually occur within 10 minutes.
• Assess
circulation,
and,
if
necessary,
provide cardiopulmonary resuscitation (CPR).
• Also check for profuse bleeding that can be controlled.
• Assess
and
begin
treatment
for
severe shock or the potential for severe shock.
• Altered Mental Status and delayed capillary refill are the most
significant signs of shock
“D”ISABILITY
• Serious central nervous system
injuries can lead to death.
• Assess the patient’s level of consciousness and,
if you suspect a head or neck injury,
apply a rigid neck collar.
• Observe the neck before you cover it up.
• Also do a quick assessment of the
patient’s ability to move all extremities.
• LOC and GCS
“E”XPOSE
• You cannot treat conditions you have not discovered.
• Remove clothing–
especially if the patient is not alert or
communicating with you–to see if
you missed any life-threatening injuries.
• Protect the patient’s
privacy, and keep the patient warm with a blanket if
necessary.
Primary Survey Continued
• As soon as the ABCDE process is completed, you
will need to make what is referred to as a
status decision of the patient’s condition.
• A status decision is a judgment about the severity of
the patient’s condition and whether the patient
requires immediate transport to a medical facility
without a secondary survey at the scene.
• Ideally, the ABCDE steps, status, and transport
decision should be completed within 10 minutes
of your arrival on the scene.
Secondary Survey
• The object of a secondary survey is to detect medical and
injury-related problems that do not pose
an immediate threat to survival but that, if left untreated,
may do so.
• Usually the trauma assessment is
about 20 percent patient interview and 80 percent
physical exam. On the other hand, the medical
assessment is 80 percent patient interview and 20
percent physical exam. Both the physical exam and patient
interview should always be done for all medical and trauma
patients.
• E.FFF.G.HH
• H.O.P.S.
HOPS- History
• History: Attitude, mental condition, and
perceived physical state.
– Stated by the athlete.
– Primary Complaint
– Mechanism of Injury
– Characteristics of the Symptoms
– Limitations
– Past History
HOPS - History
• Initial and most important step in the
evaluation process.
• In many instances, the history alone
describes the illness or injury. Physical
exam only confirms it.
HOPS -HISTORY CONT.
1. Look at the athlete.
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Anxious
Posture
Walk freely or limp
Guarding
2. Identify the chief complaint
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Why is the athlete there to see you.
3. Review previous medical history
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Acute or Chronic
Any previous injury or surgery
HOPS - History Cont.
4. Review Symptoms
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Athlete’s interpretation of injury or illness
When asking about pain use the following
PQRST
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Provocation
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What causes the pain.
Quality
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What type of pain
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Sharp, aching, dull, burning, etc….
Region/Radiating
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Location of pain, Radiating pain
Severity
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Scale of 1 to 10
Time
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When does it hurt, how long,
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What makes it better or worse
HOPS - History cont.
– At conclusion of History ask yourself was
the history AMPLE?
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A = Allergies (Bee sting, Penicillin)
M = Medicine
P = Previous Illness or Injury
L = Last thing taken by mouth
E = Events leading up to injury or illness
HOPS- Observation and Inspection
• Observation: Measurable objective
signs.
– Appearance
– Symmetry
– General Motor Function
– Posture and Gait
– Deformity, swelling, discoloration, scars,
and general skin condition
HOPS- Palpation
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Rule out FX (fracture)
Skin temperature
Swelling
Point tenderness
Crepitus
Deformity
Muscle spasm
Cutaneous Sensation (nail bed refill)
Pulse
HOPS- Special Tests
• Functional Tests
– Active Range of Motion (AROM)
– Passive Range of Motion (PROM)
– Resisted Manual Muscle Testing (RROM)
• Stress Tests
– Ligamentous Instability Tests
– Special Tests
HOPS- Special Tests
• Neurologic Tests
– Dermatomes
– Myotomes
– Reflexes
– Peripheral Nerve Testing
• Sport-Specific Functional Testing
– Proprioception and Motor Coordination
HOPS- Special Tests
• Sport-Specific Skill Performance
– Throw the football, baseball, softball, javelin...
– Kick the soccer ball, football, opponent…
S.O.A.P. Notes
• S=Subjective information gathered from
the patient
• O=Objective
• A=Assessment
• P=Plan
SOAP- Subjective
• History: Attitude, mental condition, and
perceived physical state.
– Stated by the athlete.
– Primary Complaint
– Mechanism of Injury
– Characteristics of the Symptoms
– Limitations
– Past History
SOAP- Objective:
• Observation: Measurable objective
signs.
– Appearance
– Symmetry
– General Motor Function
– Posture and Gait
– Deformity, swelling, discoloration, scars,
and general skin condition
SOAP- Objective
Rule out FX (fracture)
Skin temperature
Swelling
Point tenderness
Crepitus
Deformity
Muscle spasm
Cutaneous Sens.
Pulse
SOAP- Objective
• Functional Tests
– Active Range of Motion (AROM)
– Passive Range of Motion (PROM)
– Resisted Manual Muscle Testing (RROM)
• Stress Tests
– Ligamentous Instability Tests
– Special Tests
SOAP- Objective
• Neurologic Tests
– Dermatomes
– Myotomes
– Reflexes
– Peripheral Nerve Testing
• Sport-Specific Functional Testing
– Proprioception and Motor Coordination
SOAP- Objective
• Sport-Specific Skill Performance
– Throw the football, baseball, softball,
javelin...
– Kick the soccer ball, football, opponent…
– Macarena, Cabbage Patch, Mash Potato
SOAP- Assessment
• Analyze and assess the individual’s
status and prognosis
• Suspected injury Site
• Damaged Structures Involved
• Severity of Injury
• Progress Notes
SOAP- Plan
1. Immediate treatment given
2. Frequency and duration of treatments
and modalities and evaluation
3. On-going patient education
4. Criteria for discharge/return to play
On Field Assessment
On The Field Assessment
• History:
– Location of Pain
– Presence of abnormal neurological signs
– Mechanism of Injury
– Associated sounds (snap, crack, pop)
On The Field Assessment cont.
• Observation:
– Check the surrounding area
– Body positioning
– Movement of the athlete
– Level of responsiveness
– Primary survey
– Inspection for head or neck trauma
– Inspection of the injured body part
On The Field Assessment cont.
• Palpation
– Joints
– Bones
– Soft tissue
– Skin temperature
On The Field Assessment cont.
• Functional Testing
– Active Range of Motion (AROM)
– Passive Range of Motion (PROM)
– Resistive Range of Motion (RROM)
– Weight Bearing
On The Field Assessment cont.
• Stress Testing
– Ligamentous stability
• Neurological Testing
– Cutaneous
– Motor
On The Field Assessment cont.
• Vital Signs
– Pulse
– Respiratory Rate
– Blood Pressure
– Temperature
– Skin Color
– Pupils
– Disposition
On The Field Assessment cont.
• Moving the Athlete
– Ambulatory Assist
– Manual Conveyance
– Spine Board
– Pool Extraction
Physician Ordered Tests
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Blood Test
Radiographs (X-Ray)
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
Radionuclide Scintigraph (Bone Scan)
Ultrasonic Imaging
Electromyography (EMG)
Special Tests
X-ray
MRI
Special Test cont.
CT scan
Bone Scan
Special Tests cont.
Ultrasound
Electromyography - EMG