The highly dependent patient may be receiving sedation, the purpose of which is to promote comfort, help the patient to sleep with minimal disturbance, reduce anxiety and facilitate nursing and medical interventions (Gwinnutt 2006). The ideal level of sedation produces a calm and relaxed patient who complies with interventions. However, the effects of over- or undersedation are widely recognised (Gwinnutt 2006).
The most commonly used sedative agents are propofol and midazolam (Gwinnutt 2006). Patients receiving these drugs should be assessed using an appropriate sedation scoring tool on a regular basis.
Outdated tools such as the Ramsey Scale (Ramsey et al. 1974) can still have a place in HDU, but more recent tools such as the Richmond Agitation Sedation Scale (Sessler et al. 2002) are more appropriate for ICU.
The other issue to consider in HDU is the risk of delirium. Up to 80% of patients experience delirium at some stage during their stay (Page & Ely 2011). Many factors contribute to delirium, including lack of sleep, surgical procedures, drugs and age. Tools such as the CAM ICU can be useful for assessing delirium (Page & Ely 2011), and although it may be difficult to prevent, recognising and treating delirium is essential.
Pain control
Pain is assessed under ‘Disability’ during the ABCDE assessment or when calculating an early warning score (Jevon 2010). Many pain assessment tools exist, but in reality a scale of 0–3 is commonly used whereby three reflects the most severe pain imaginable and zero reflects no pain. This can then be used to guide the analgesic ladder advocated by the World Health Organization (1996). On the first step of the ladder, mild pain, drugs such as paracetamol or non-steroidal anti-inflammatory drugs are administered. The second step, moderate pain, involves the use of weak opioids such as dihydroco- deine or codeine, in conjunction with non-opioids. With the final step, severe pain, strong opioids such as morphine or diamorphine are administered (World Health Organization 1996).
Analgesia can be administered by the intravenous, subcutaneous or oral route in HDU. Patient- controlled analgesia is also used, enabling patients to control their pain themselves within set param- eters (applied by a preset dose lock-out). However, although there are documented benefits, there is
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also evidence that these systems are difficult to use (Mackintosh 2007). An alternative approach for the postoperative patient is epidural analgesia. However, epidurals can cause problems such as hypo- tension, weakness and numbness, and can even be misplaced (Moore & Woodrow 2009). The high- dependency nurse must therefore be vigilant and follow strict hospital protocols for managing epidurals.
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www.wileyfundamentalseries.com/medicalnursing
Conclusion
Caring for the highly dependent patient can be both challenging and rewarding. Not only does it provide the nurse with the opportunity to deliver high standards of person-centred care for an unstable, dete- riorating or recovering patient, but there are tremendous learning opportunities as well. The patient is also normally awake and conscious, which makes communication much easier than in an ICU envi- ronment. Providing psychological support for patients and their families during this stressful period is a fundamental aspect of care. This chapter has discussed the role and function of high-dependency care in the UK. The importance of a thorough systematic respiratory, cardiovascular and neurological assessment has also been discussed, along with some of the key nursing interventions in HDU.
Visit www.wileyfundamentalseries.com/medicalnursing and read Reflective Question 9.2 to think more about this topic.
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Principles of
emergency nursing
Valerie Small 1 , Gabrielle Dunne 1 and Catherine McCabe 2
1Emergency Department, St James’s Hospital, Dublin, Ireland
2School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
10
Contents
Introduction 143
Historical context of emergency nursing 143
Triage 143
Common surgical emergencies 144
Common medical emergencies 145
Patient assessment in the ED 145
Advanced life support 146
Assessment and stabilisation of emergency
trauma conditions 146
Minor trauma 148
Burns 148
Head injuries 151
Assessment and stabilisation of adverse
behavioural presentations 152
Care of the critically ill and dying patient
in the ED 152
Conclusion 153
References 153
Having read this chapter, you will be able to understand:
•
The nurse’s role as a member of the emergency care team•
The principles of triage•
The principles of advanced life support•
The assessment and stabilisation of emergency medical, surgical or trauma conditions•
The assessment and stabilisation of adverse behavioural presentations•
The care of the critically ill and dying patient in the emergency departmentLearning outcomes
Fundamentals of Medical-Surgical Nursing: A Systems Approach, First Edition. Edited by Anne-Marie Brady, Catherine McCabe, and Margaret McCann.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.
143
Introduction
This chapter presents an overview of the role of the healthcare team in emergency care, rapid assess- ment and the very broad and diverse nature of the types of medical, surgical, social and behavioural conditions that are treated in emergency departments (EDs). Nursing students’ experience in EDs is often very limited, but through the use of scenarios this chapter provides an insight into the challeng- ing, dynamic and rewarding aspects of working in an ED.
During your clinical placement in the ED, become familiar with the resuscitation area and how it is prepared for trauma patients. Ask your mentor or preceptor to demonstrate the systematic initial assess- ment and management of the trauma patient in a simulated clinical situation (although during trauma care training the sequence is presented in a longitudinal process of events, whereas in the actual clinical situation many of these activities occur simultaneously). Finally, observe the assessment, stabilisation and management (including the log roll) of major trauma patients during your placement.