Emergency Management – refers to care given to patients with urgent and critical needs. However, because many people lack access to health care, the emergency department is increasingly used for non-urgent problems. Therefore, the philosophy of emergency management has broadened to include the concept that an emergency is whatever the patient or the family considers it to be.
The emergency nurse has had specialized education, training, experience, and expertise in assessing and identifying patient’s health care problems in crisis situations.
2. The emergency nurse establishes priorities, monitors and continuously assesses acutely ill and injured patients, supports and attends to families, supervises allied health personnel, and teaches patients and families within a time-limited, high-pressured care environment
3. Nursing interventions are accomplished interdependently, in consultation with or under the direction of a physician or nurse practitioner. The strengths of medicine and nursing are complementary in an emergency situation. Appropriate nursing and medical interventions are anticipated based on assessment data. The emergency health care staff members work as a team in performing the highly technical hands-on skills required to care for patients in emergency situations.
4. Patients in the ER have a wide variety of actual or potential problems, and their condition may change constantly. Therefore, nursing assessment must be continuous, and nursing diagnoses change with the patient’s condition. Although a patient may have several diagnoses at a given time, the focus is on the most life-threatening ones; often both independent and interdependent nursing interventions are required.
e. Patients from prison and those who are under guard need to be handcuffed to the bed and appropriately assessed to ensure the safety of the hospital staff and other patients.
e.1. never release the hand or ankle restraint (handcuff)
e.2. always have a guard present in the room.
e.3 place the patient face down on the stretcher to
avoid injury from head-butting, spitting, or biting.
e.4 use restraints on any violent patient as needed.
e.5. administer medication if necessary to control
violent behavior until definitive treatment can be
f. In the case of gunfire in the ER, self-protection is a priority. There is no advantage to protecting others if the caregivers are also injured. Security officers and police must gain control of the situation first, and then care is provided to the others.
☻ the unconscious patient should be treated as if conscious; that is, the patient should be touched, called by name, and given an explanation of every procedure that is performed.
b. Family-focused interventions
☻ The family is kept informed about where the patient is, how he/she is doing, and the care that is being given. Allowing the family to stay with the patient, when possible also helps allay their anxieties
Guidelines in Helping Family Members Cope with Sudden Death
1. Take the family to a private place.
2. Talk to the family together, so that they can mourn together.
3. Reassure the family that everything possible was done; inform them of the treatment rendered.
4. Avoid using euphemisms such as “passed on”. Show the family that you care by touching, offering coffee, water, and the services of the chaplain.
5. Encourage family members to support each other and to express emotions freely (grief, loss, anger, helplessness, tears, disbelief).
6. Avoid giving sedation to family members; this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression.
7. Encourage the family to view the body if they wish; this action helps to integrate the loss. Cover disfigured and injured areas before the family sees the body. Go with the family to see the body. Show acceptance by touching the body to give the family “permission” to touch.
8. Spend time with the family members to talk about the deceased and what he/she meant to them; this permits ventilation of feelings of loss. Encourage the family to talk about events preceding admission to the ER. Do not challenge initial feelings of anger and denial.
9. Avoid volunteering unnecessary information (e.g., the patient was drinking)
☻ By definition, emergency care is care that must be rendered without delay. In an ER, several patients with diverse health problems-some life threatening, some not – may present to the ED simultaneously. One of the first principles of emergency care is triage.
TRIAGE – comes from the French word “ trier”, meaning “ to sort”. In the daily routine of the ER, triage is used to sort patients into groups based on the severity of their health problems and the immediacy with which these problems must be treated.
1. Resuscitation – patients need treatment immediately to prevent death.
2. Emergent - patients may deteriorate rapidly and develop a major life threatening situation or require time-sensitive treatment.
3. Urgent – Patients have non-life threatening conditions but require two or more resources to provide their care. If the patients’ vital signs deviate significantly from their baseline, they may require “up-triaging” to the emergent category.
4. Nonurgent- patients have non-life threatening conditions and likely need only one resource to provide for their needs.
5. Minor category – patients have no life-threatening conditions and likely require no resources to provide their evaluation and management.
☻ Resources are defined as imaging studies, medications administered IV or IM routes, and invasive procedures. Insertion of an indwelling catheter is an example of a one-resource procedure. Moderate sedation would be classified as a two-resource procedure because this requires frequent monitoring and IV medications.
☻ A systematic approach to effectively establish and treat health priorities is the primary / secondary approach. The primary survey focuses on stabilizing life-threatening conditions. The ER staff work collaboratively and follow the ABCD (airway, breathing, circulation, disability method:
1. Establish a patent airway.
2. Provide adequate ventilation, employing resuscitation measures when necessary. (trauma patients must have the cervical spine protected and chest injuries assessed first).
3. Evaluate and restore cardiac output by controlling hemorrhage, preventing and treating shock, and maintaining or restoring effective circulation. This includes the prevention and management of hypothermia.
4. Determine neurologic disability by assessing neurologic function using the Glasgow Coma Scale.
1. Hypovolemic shock – refers to a state in which the volume contained within the intravascular compartment is inadequate for perfusion of body tissue. There is usually a 15%-25% reduction of intravascular volume.
e.g., hemorrhagic shock – loss of whole blood about 1/3 of his normal blood volume
2. Cardiogenic shock – which occurs when the heart has an impaired pumping ability; it may be of coronary or noncoronary event origin.
3. Septic shock- which is caused by an infection
4. Neurogenic shock- which is caused by alterations in vascular smooth muscle tone, caused by either nervous system injury or complications associated with medications such as epidural anesthesia.
5. Anaphylactic shock – which is caused by hypersensitivity reaction.
1. identifying the cause of the shock, correcting the underlying disorder so that shock does not progress, and supporting those physiologic processes that thus far have responded successfully to threat.
2. Fluid replacement and medication therapy must be initiated to maintain an adequate BP and reestablish and maintain adequate tissue perfusion.
2. Cardiovascular Effect - ischemia and dysrhythmia due to lack of adequate blood supply, the HR is rapid, sometimes exceeding 150 bpm. The patient may complain of chest pain and even suffer a myocardial infarction.
Levels of cardiac enzymes increase.
myocardial depression and ventricular dilation may further impair the heart’s ability to pump enough blood to the tissues to meet oxygen requirements.
3. Neurologic Effects- mental status deteriorates and occur with decreased tissue perfusion and hypoxia. Initially, patient may exhibit a subtle change in behavior or agitation and confusion. Subsequently, lethargy increases, and the patient begins to lose consciousness.
3. Hepatic effects – decreased blood flow to the liver impairs the ability of the liver cells to perform metabolic and phagocytic functions. The patient is less able to metabolize medications and metabolic waste products, such as ammonia and lactic acid.
☻ Metabolic activities of the liver (gluconeogenesis and glycogenolysis) are impaired. The patients become more susceptible to infection as the liver fails to filter bacteria from the blood.
☻ Liver enzymes and bilirubin levels are elevated and the patient appears jaundiced.
4. Renal Effects – GFR decreases. ARF may develop (increased BUN, crea), fluid and electrolytes shift, acid-base imbalances and a loss of renal-hormonal regulation of BP.
5. GI effects – can cause stress ulcers in the stomach, putting the patient at risk for GI bleeding. In the small intestine, the mucosa can become necrotic and slough off, causing bloody diarrhea.
6. Hematologic Effects – the combination of hypotension, sluggish blood flow, metabolic acidosis, coagulation system imbalance, and generalized hypoxemia can interfere with normal hemostatic mechanism.
monitor the patient for early signs of complications. It includes evaluating blood levels of medications, observing invasive vascular lines for signs of infection, and checking neurovascular status if arterial lines are inserted.
frequent oral care, aseptic suction technique, turning, and elevating the head of the bed to prevent aspiration.
c. positioning and repositioning of the patient to promote comfort and maintain skin integrity.
2. Promoting Rest and comfort to minimize the cardiac workload.
☻ The most common and serious side effects of fluid replacement are cardiovascular overload and pulmonary edema .
1. Monitor frequently the urine output, changes in mental status, skin perfusion, and changes in vital signs.
2. Lung sounds are auscultated frequently to detect signs fluid accumulation. Adventitious lung sounds, such as crackles may indicate pulmonary edema.
3. A CVP may be inserted to monitor the patient’s response to fluid replacement.
4. Vasoactive medications to restore vasomotor tone and improve cardiac function.
5. Nutritional support to address the metabolic requirements that are often dramatically increased in shock. Patient in shock may require 3000 calories daily. The release of catecholamines early in shock continuum causes depletion of glycogen stores in about 8-10 hours.
☻ Is the most common type of shock and is characterized by a decreased intravascular volume. Body fluids is contained in intracellular and extracellular compartments. Intracellular fluids account for about 2/3 of the total body water. Hypovolemic shock occurs when there is a reduction in intracellular volume by 15%-25%, which represents a loss of 750 – 1300 ml of blood in a 70-kg person.
☻ Occurs when the heart’s ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues
1. Coronary cardiogenic shock – occurs when a significant amount of the left ventricular myocardium has been damaged.
2. Noncoronary cardiogenic shock – are related to conditions that stress the myocardium (e.g., severe hypoxemia, acidosis, hypoglycemia, hypocalcemia, and tension pneumothorax) as well as conditions that result in ineffective myocardial function (e.g., cardiomyopathies, valvular damage, cardiac tamponade, dysrhythmias)
a. In the case of coronary cardiogenic shock, the patient may require thrombolytic therapy, angioplasty, CABG, intra-aortic balloon pump therapy, or some combination of these treatments.
b. In the case of noncoronary cardiogenic shock, interventions focus on correcting the underlying cause, such as replacement of a faulty cardiac valve, correction of dysrhythmias, correction of acidosis and electrolyte disturbances, or treatment of the tension pneumothorax.
2. Initiation of First-Line treatment
supplying supplemental oxygen
controlling chest pain
providing selected fluid support
administering vasoactive medications
controlling HR with medication or by implementation of a transthoracic IV pacemaker.
☻ Occurs when blood volume is abnormally displaced in the vasculature (e.g., when blood pools in peripheral blood vessels). Circulatory shock can be caused either by a loss of sympathetic tone or by release of biochemical mediators from cells.
Septic Shock: shock associated with sepsis; characterized by symptoms of sepsis plus hypotension and hypoperfusion despite adequate fluid volume replacement
1. Identification of the cause of infection. Specimens of blood, sputum, urine, wound drainage, and tips of invasive catheters are collected for culture using aseptic technique.
2. Any potential source must be eliminated. IV lines are removed and reinserted at other body sites. Antibiotic-coated IV central lines may be inserted to decrease the risk of invasive line-related bacteremia in high risk patients, such as elderly.
3. Fluid replacement must be instituted to correct the hypovolemia that results from incompetent vasculature and the inflammatory response.
☻ vasodilation occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation. The patient experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period leading to a relative hypovolemic state. However, blood volume is adequate, because the vasculature is dilated; the blood volume is displaced, producing hypotensive state resulting to a drastic decrease in the patient’s systemic vascular resistance and bradycardia. Inadequate BP results in the insufficient perfusion of tissues and cells.
1. Spinal cord injury, spinal anesthesia, or nervous system damage.
2. Depressant effect of medications or from lack of glucose.
1. Elevate and maintain the head of the bed elevated at least 30 degrees to prevent neurogenic shock when a patient receives spinal or epidural anesthesia. Elevation of the head helps prevent the spread of the anesthetic agent up to the spinal cord.
2. In suspected spinal cord injury, neurogenic shock may be prevented by carefully immobilizing the patient to prevent further damage to the spinal cord.
3. Support CV and neurologic function until the usually transient episode of neurogenic shock resolves. Applying elastic compression stockings and elevating the foot of the bed may minimize the pooling of blood in the legs
4. Administration of heparin or LMWH (Lovenox) as prescribed, application of elastic compression stockings, or use of pneumatic compression of the legs may prevent thrombus formation.
5. Passive ROM of the immobile extremities helps promote circulation.