Acute Care Nursing|2023 LATEST UPDATE|GUARANTEED SUCCESS

What is the Emergency Severity Index (ESI) A triage color coded system: 1. Red = unstable/see immediately 2. Red = threatened/see within 10 min 3. Yellow = stable (caution/watch)/see within 1 hr 4. Green = stable/ 5. Green = stable Blue & Black = death or dying What differentiate's the ESI levels? The level of care they need - can they survive? What is the role of an acute care (ER) nurse? -to triage - to sort and recognize urgency of s/sx -to conduct an accurate initial assessment within 15 seconds -obtain pertinent history -to initiate priority interventions immediately if not breathing! -to provide emotional support Emergency Assessment is broken down into a two-part system: Primary and Secondary survey Primary Survey GOAL: identify life threatening conditions (within 1 minute of any emergency) C-circulation A-airway B-breathing D-disability/deficit E-exposure/environment (Primary) Circulation What would I do during this part of the assessment? ASSESSMENT: -check carotid or femoral pulse *if pulse is absent, initiate CPR & ALS measures -check pulses for quality and rate *if shock symptoms or hypotensive, start lg bore (14-16g) IV's and initiate infusions of normal saline or lactated Ringer solution -Assess skin color, temp, moisture -check capillary refill -assess for external bleeding -measure blood pressure INTERVENTIONS: -control bleeding with direct pressure and pressure dressings -administer blood products if ordered -consider autotransfusion if isolated chest trauma -consider use of pneumatic anti-shock garment or pelvic splint in the presence of pelvic fracture with hypo-tension -obtain blood samples for type and crossmatch POTENTIAL LIFE THREATENING CONDITIONS: -direct cardiac injury (ex: MI, trauma) -pericardial tamponade -shock (ex: massive burns, hypovolemia) -hypothermia (Primary) Airway What would I do during this part of the assessment? ASSESSMENT: -assess for respiratory distress -assess airway for patency -check for loose teeth or foreign bodies -assess for bleedin, vomitus or edema INTERVENTIONS: -open airway -use jaw-thrust maneuver -remove or suction any foreign bodies -intubate if necessary -immobilize cervical spine using collar and secure forehead to backboard POTENTIAL LIFE THREATENING CONDITIONS: -inhalation injury (ex: fire victim) -obstruction (partial or complete) from foreign bodies (ex: vomitus) or tongue -penetrating wounds and/or blunt trauma to upper airway structures (Primary) Breathing What would I do during this part of the assessment? ASSESSMENT: -assess for ventilation -scan chest for signs of breathing -look for paradoxic (opposite of normal chest breathing) movement of the chest wall during inspiration and expiration -note use of accessory muscles or abdominal muscles -observe & count respiratory rates -note color of nail beds, mucous membranes & skin -ascultate lungs -assess for jugular vein distention and position of trachea INTERVENTIONS: -give supplemental O2 via appropriate delivery system (ex: non-rebreather, NC, etc.) -ventilate with bag-valve mask with 100% O2 if respiration are inadequate or absent -prepare to intubate if sever respiratory distress (ex: agonal breaths) or arrest -have suction available -if absent breath sounds, prepare for needle thoracostomy (make hole in chest wall for tube insertion) and insert chest tu be POTENTIAL LIFE THREATENING CONDITIONS: -anaphylaxsis -flail chest with pulmonary contusion -hemothorax (blood in pleural space) -pneumothorax (open, tension) (Primary) Disability What would I do during this part of the assessment? ASSESSMENT: -Brief Neurologic Assessment *assess LOC by determining response to verbal and/or painful stimuli *assess pupils for size, shape, equality & reactivity -Identify Deformities *inspect extremities for any obvious deformities *determine range of movement and strength in extremities -Brief Pain Assessment *assess pain INTERVENTIONS: -periodically reassess LOC, mental status, pupil size and reactivity -immobilize any obvious skeletal deformities -periodicaly reassess pain using standardized pain scale POTENTIAL LIFE THREATENING CONDITIONS: -head injury -stroke (Primary) Exposure and Environmental Control What would I do during this part of the assessment? ASSESSMENT: -assess full body for additional or related injuries INTERVENTIONS: -remove clothing for adequate examination -keep patient warm with blankets, warmed IV fluids, overhead light to prevent heat loss, if needed -maintain privacy POTENTIAL LIFE THREATENING CONDITIONS: - Secondary Survey (F, G, H, I) GOAL: to identify all injuries that may lead to disability/death F=full set of VS (in both arms in case there is an aorta tear) G=give comfort measures & emotional support (this can be therapeutic for pt & family; allows time for more Hx on pt) H=head to toe (more concentrated than 1st exam) exam I=inspect all areas thoroughly, including posterior INTERVENTIONS: -five major interventions: *12 lead ECG *continuous O2 monitoring *NG/OG tube (to decompress belly of air & food) *foley (get accurate I&O's to measure fluid loss) *additional labs &meds (tells if there is bleeding, cardiac enzymes, etc.) What additional info from Head-to-Toe could you get? -chief complaint from patient and/or EMT, family, friend -if able, the patient's description of pain -a witness description of incident and patient's behavior What does the mnemonic A-M-P-L-E stand for? A=allergies M=medications P=past health hx (ex: preexisting medical condition, mental status, menstrual period) L=last meal E=events/environmental conditions preceding illness or injury Neurological Assessment - what would I perform? -note any change in mental status, espcially if different from initial survey *this can be an early warning sign of a neuro event and requires immediate intervention -assess LOC *if unresponsive, check responses to painful stimuli (GSC) -check pupils *PERRLA -assess ability to open mouth/swallow -check muscle strength -assess hand grasps -is there any posturing? -hemiplegia or quadraplegia? -any sensations? -ask patient or family members about any: *dizziness, HA, vertigo, tinnitus, weakness, dysphagia, dysarthria, numbness, paralysis, pain confusion, recent illness What would I assess for the chest/lungs? -examine chest, front & back (airway was done in primary) -look for paradoxical chest movements (moving in opposite directions) -listen more thoroughly to heart and breath sounds -distended neck veins = JVD (possible HF or hypervolemia) -always consider possible chest injuries (blunt or subtle) -examine 12 lead ECG to evaluate CP, cardiac contusion, possible MI and/or dysrhythmias -CXR What would I do during the abdominal assessment? -look for (with mechanism of injury and hx of event in mind....): *distention *symmetry *contusion *abrasion *penetrating wound *"seat belt signs" and "cullen's sign" -auscultate BS, listen for bruits -percuss abdomen for tympani or dullness -fractured ribs: esp #'s 10-12 as they can cause liver/kidney damage -liver trauma (ALWAYS be suspicious with abdomen injury until ruled out!) -suspect renal trauma if there is a lower posterior rib, lumbar or flank injury WHAT DIAGNOSTIC TESTS WOULD BE DONE? -rapid evaluation for peritoneal bleeding -abdomen ultrasound or F.A.S.T; CT scan; possibly a peritoneal lavage What would I do during the Pelvic assessment? -palpate pelvis gently; if painful it may indicate a fracture (fx) *set in traction using a sheet -palpate bladder: check for distension, asymmetry, hematuria (blood in urine), dysuria (painful urination), oliguria (small amt urine), anuria (kidneys fail to produce urine) or retention -inspect genitalia for bleeding and obvious injury -rectal exam for presence of blood and possible injury