33.1 Triage and Assessment
- The ACBDE assessment method is utilized to triage patients. The patient’s airway is assessed first, then breathing, circulation, neurological disability, and exposure.
- Emergency department nurses use triaging to guide the implementation of care for their patients. ED nurses must triage and stabilize patients with the most life-threatening conditions first.
- Components of effective documentation include assessment findings, medical histories, and communication with patients, families, and other members of the health-care team. Nurses should also document medications appropriately and provide updates to the patient’s plan of care and outcomes.
- Subjective assessment findings, or symptoms, are those aspects of the patient’s condition that the patient feels or tells the nurse about and that cannot be directly observed or measured.
- Objective assessment findings, or signs, are those conditions that the nurse can directly observe or measure.
- In the event of a life-threatening emergency where the patient is unconscious or unable to communicate, implied consent is warranted.
- Minors who come to the emergency department must receive an initial medical screening for emergency conditions. If there is a life-threatening injury, then the health-care team may proceed with care. It should, however, first exhaust all efforts to obtain consent from the minor’s parents or legal guardian.
33.2 Types of Emergency Care
- The ABCDE triage assessment is best practice when performing an initial assessment on trauma patients.
- Crush injuries occur from prolonged pressure to an area and can either be traumatic or nontraumatic. Subsequent muscle injury releases myoglobin and other components into the bloodstream causing health complications.
- Rapid fluid resuscitation is key with crush injuries to prevent complications, such as rhabdomyolysis, shock, and acute kidney injury. Nurses must promote outcomes, such as improving revascularization, treating electrolyte disturbances, and maintaining patient stability.
- Accidental poisoning occurs when a person accidentally exposes themselves to toxic levels of a substance. Intentional poisoning can be caused by a person intentionally exposing themselves to toxic substances or by another person intending harm.
- Nurses provide support care, such as monitoring vital signs and promoting hemodynamic stability. They administer antidotes and anti-epileptic medications as ordered.
- Maltreatment is poor treatment or care of an individual and encompasses abuse and neglect.
- Types of abuse include child, elder, sexual, and domestic partner abuse.
- Nurses must perform a complete history and physical assessment when abuse is confirmed or suspected, thoroughly documenting findings and reporting to the appropriate channels immediately.
- As mandated reporters, nurses are required by law to report suspected or confirmed abuse of any type or to any person.
- Examples of psychiatric emergencies range from suicide attempts to acute psychosis, and from intoxication and drug overdose to delirium tremens.
- When a patient is involuntarily admitted to a health-care facility under law, this is a psychiatric hold. State laws governing psychiatric holds vary.
- Safety is a nurse’s top priority when caring for patients with psychiatric emergencies.
- Examples of drugs frequently encountered in the emergency department include opioids, alcohol, methamphetamine, cocaine, and marijuana.
- Opioid and heroin overdoses cause respiratory and nervous system depression and potentially lead to death.
- Patients withdrawing from alcohol can develop delirium tremens, a severe condition that can present with seizures, and can sometimes lead to death.
- The CIWA scale is used for alcohol withdrawal and the COWS is for opioid withdrawal. Nurses provide supportive measures to control withdrawal symptoms, prevent dehydration, and collaborate with psychiatric care.
33.3 Managing Risk Exposure
- Nurses utilize risk assessment tools, such as the Triage Tool or Danger Assessment Tool, to readily identify potential violent patient behaviors.
- Methods for mitigating violence include establishing a workplace culture of respect, receiving violence prevention training, implementing zero-violence workplace policies, and developing a framework for outcome reporting.
- Some safety actions nurses can take include dressing safely, always being aware of their surroundings, and following de-escalation techniques, like establishing a calm environment or not using medical jargon when they speak.
- Wearing proper personal protective equipment when there is potential exposure to chemicals, drugs, or communicable disease is the first step to preventing disease and bloodborne pathogen transmission.
- Stress management strategies include promoting self-care and safety and seeking support from others or employee assistance programs.
33.4 Forensic Nursing
- Forensic nurses often work in the emergency department and are specifically trained to examine patients who are victims of acts of violence or abuse.
- A forensic nurse follows set protocols for collecting and preserving evidence.
- Evidence collection involves collecting a thorough history, taking photographs, gathering samples, and completing the required documentation and a chain of custody form.
- A SANE nurse is a forensic nurse who is trained in sexual assault examinations and gathering evidence and uses a SAECK to collect evidence samples from the patient.
33.5 Transferring from the Emergency Department
- The framework for optimal discharge planning is an ongoing process, including initial screening, care coordination, and post-discharge follow-up.
- Health-care organizations must continuously re-evaluate their best practices for patient transfers. ED team members and nurses must appropriately triage patients and assign their acuity level.
- Nurses must ensure that patients are stable prior to transfer. Vital signs should be stable, orders and diagnostic tests should be completed, medications should be administered, and continuous infusions and drains/lines should be inserted, as needed.
- The SBAR tool is the recommended tool for nurses to utilize during patient transfer to communicate effectively and concisely.
- Nurses should review follow-up instructions with patients about their discharge care and signs and symptoms of worsening conditions.
- Determining the patient’s social determinants of health that can affect the patient’s care after discharge.