Nurses in the ED have a lot of autonomy due to….
good critical thinking skills
What is the number 1 priority Emergency measure for ALL patients?
–SAFETY
Why is preplanning used in Emergency measures?
ensures security and safe environment for everyone
Why should the nurse closely monitor the patient and family members?
everyone reacts differently to stress, they may become violent.
What are some patient and family focused interventions?
- -Relieve anxiety
- -Allow family to stay with pt.
- -Explain and inform pt. of all care given
Triage means to….
sort
How does triage work in the ED?
The most critically ill receives the most resources and care first, regardless of potential outcome
What does a triage nurse do?
collects data and classifies illnesses and injuries
When discharging a patient home the nurse must…
give verbal and written instructions and document verbal and written instructions given.
A primary survey is always done, especially if they are a trauma patient. What is the order of the primary survey?
“ABCDE”
- -Airway (patent?)
- -Breathing (ventilation?)
- -Circulation (restore CO–>prevent/treat shock)
- -Disability (neuro)
- -Exposure
When assessing disability with the primary survey. what acronym should the nurse use?
“AVPU”
- -Alert?
- -Verbal (respond to verbal stimuli?)
- -Pain (respond to painful stimuli?)
- -Unresponsive
What should the nurse do to perform the exposure part of the primary survey?
- -undress pt. quickly (expose skin)
- -Inspect, percuss, auscultate, palpate
- -skin color?
- -Unusual skin markings?
- -Body odors?
What is the secondary survey used for?
The nurse identifies other non life-threatening problems.
The secondary survey includes….
- -health history
- -head to toe assessment
- -diagnostics/labs
- -monitoring devices
- -splinting
- -wound care
- -comfort care, support
What acronym should be used when assessing pain?
PQRST
What does PQRST stand for?
- -Provokes (what causes/provokes pain?)
- -Quality (sharp, dull, aching, throbbing)
- -Region/radiation (where? does it radiate?)
- -Severity (rate scale 1-10)
- -Timing (how long had pain? constant?)
What are some ways to manage an airway?
- -Oropharyngeal/nasopharyngeal airway insertion
- -endotracheal intubation
- -King tube, laryngeal mask
- -Cricothyroidotomy
- -ventilation (bag valve mask, c-pap, bi-pap)
How can hypovolemic shock be prevented?
manage hemorrhage
Wounds is another priority emergency measure. What should the nurse consider?
- -control bleeding
- -prevent contamination/infection
