Medical-Surgical Nursing: An Integrated Approach, 2E

Chapter 37

NURSING CARE OF THE CLIENT: RESPONDING TO EMERGENCIES

Emergency: Defined as:

A medical or surgical condition requiring immediate or timely intervention to prevent permanent disability or death.

In the U.S., trauma is the number one killer of those under the age of 37 and the fourth leading cause of death overall.

Emergency Nursing The care of clients who require

emergency intervention. The emergency nurse must be capable of

rapid assessment and history taking and immediate intervention formulation and implementation using the nursing process.

Clinical knowledge, communication, client teaching, and empathy skills are essential.

Approaches to Emergency Care

There are three general approaches to emergency care: Hospital triage. Disaster triage. Emergency medical services.

Hospital Triage

Triage refers to classification of clients to determine priority of need and proper place of treatment.

Each hospital with an emergency department (ED) has an established triage system in place.

Golden Rules of Emergency Care

1. Establish the safety of the scene.2. Remove the client from danger.3. Establish airway, breathing, and

circulation.4. Manage shock.5. Attend to eye injuries.6. Treat skin injuries.7. Call for help.

Triage Classifications

Emergent (clients who require immediate care in order to sustain life or limb).

Urgent (clients who require care within 1 to 2 hours to prevent worsening of their condition).

Non-urgent (clients whose care can be delayed without the risk of permanent consequences).

Disaster Triage

Immediate Simple injuries

requiring immediate care

Chest wounds

Crush injuries

Burns

Delayed Multiple injuries

requiring extensive care

Open fractures of the long bones

Minimal Minor injuries (the walking wounded)

Sprains, minor cuts

Contusions

Expectant Severe injuries likely to cause death

Massive head trauma, spinal cord injuries

CATEGORY CLIENT NEEDS EXAMPLES

Emergency Medical Services Prior to admission to the ED, the client may

have been cared for by an emergency medical technician (EMT) or paramedic.

An EMT is a health care professional trained to provide basic lifesaving measures prior to arrival at the hospital.

A paramedic is a more specialized health care professional trained to provide advanced life support to the client requiring emergency interventions.

Shock: Defined as:

A condition of profound hemodynamic and metabolic disturbance characterized by inadequate tissue perfusion and inadequate circulation to the vital organs.

Types of ShockTYPE CAUSES

Hypovolemic Hemorrhage; Burns

Cardiogenic Myorcardial Infarction

Toxic Overwhelming Infection

Anaphylactic Medications, insect bites or stings, food

Neurogenic Spinal cord injury

Cardiopulmonary Emergencies

Those that jeopardize the function of the hearts and lungs.

Include drowning, foreign body obstruction of the airway, chest trauma, and chest pain.

Neurological/Neurosurgical Emergencies

Head injuries are the most common type of neurological trauma.

Spinal cord trauma can also occur as a result of injuries sustained in a head injury.

Head injuries most common in motor vehicle collisions.

Cerebrovascular accidents, or stroke, also require emergency care.

Abdominal Emergencies

Abdominal emergencies can be diverse in nature.

Include trauma as well as illnesses that cause abdominal pain (gastroenteritis, gastrointestinal bleeding, etc.).

Genitourinary Emergencies

Include rape. Straddle injuries (those that occur when a

client falls while straddling an object, such as a fence or metal bar, thereby injuring the perineum).

Ocular Emergencies

Most eye emergencies are urgent to emergent in nature.

Foreign bodies can cause damage to vision very rapidly and thus require immediate attention.

Musculoskeletal Emergencies

Can vary from simple strains to major trauma.

Includes sprains, dislocations, fractures.

Soft Tissue Emergencies

Most soft-tissue injuries are very common, including minor abrasions, lacerations, puncture wounds, contusions, bites of all varieties, and burn injuries.

Although most do not require emergency care, some are more severe than others and some are potentially fatal.

Poisoning and Overdoses

Can be accidental or intentional. Ingested poisons are most common. Important to obtain a clear history of the

route of entry: inhalation, ingestion, topical, or injection.

Environmental/Temperature Emergencies

Exposures to extremes of heat and cold can be potentially life threatening.

Severe cold, or hypothermia, frostbite, extreme heat are examples.

Degrees of Frostbite Severity

Mild Skin cold to touch, pale, tingling, numb

Use blankets, warm clothing to warm cold flesh

Moderate Affects deeper body tissue, skin waxy, puffy, itchy, burning with pain

Use gloves, blankets, warm clothing to warm cold flesh

Severe Blistering, soft tissue damage, flesh hard, lifeless, no pain

Initiate emergency rewarming using warm water baths; observe for edema

DEGREE SYMPTOMS TREATMENT

Comparison of Heat Injuries

Heat Cramps Muscle cramps in arms, leg, and abdomen

Move client to cool, shady area. Slowly administer copious water. Reevaluate.

Heat Exhaustion Diaphoresis, pale, moist, cool skin, headache, dizziness, etc.

Move client to cool, shady area. Pour water over client. Elevate legs.

Heat Stroke (medical emergency)

Red, flushed, hot dry skin; no diaphoresis.

Emergency treatment.

TYPE SYMPTOMS TREATMENT

Multiple System Trauma

Injury sustained in more than one body system.

During the initial care of the emergency client, the mechanism of injury is determined.

Blunt injuries and penetrating trauma are most likely to result in multiple-system involvement.

Legal Issues

Nurses must be aware of the legal issues related to emergency care, such as Good Samaritan Laws and mandated reporting.

Death in the Emergency Department Death can occur in the ED at any time

due to trauma, sudden illness, or even extended illness.

In the event of sudden death, the family is usually in a state of shock and will need further assistance to cope with the death of their loved one.

Special support groups are available for this assistance and should be contacted for the family.