The information in this book has been compiled based on basic knowledge of the emergency department, and the sources used are believed to be reliable. First, all of the listed interventions beyond the scope of nursing must be performed under the direction of an emergency room (ER) provider.
FAST FACTS FOR THE ER NURSE
INTRODUCTION
SYMPTOMS OF STRESS
Fast facts in a nutshell
TECHNIQUES FOR RELIEVING STRESS
No matter how much experience you have in the emergency room, you can still learn something new every day. Document how they were when they left the emergency room (e.g., ambulatory, stable, not in acute distress) and reassess the ABCs.
Fast facts in a nutshell: summary
The body requires a delicate balance of acids and bases to maintain natural homeostasis. Many life-threatening diseases affect the acid-base balance. Understanding the pathophysiology and reviewing the many laboratory results are key to better understanding acid-base imbalances.
PATHOPHYSIOLOGY
Respiratory System
Renal System
Recognizing an Imbalance
The arrows in Table 2.1 for respiratory pH and PaCO2 are in opposite directions to each other, and the arrows for metabolic pH and bicarbonate are equal or in the same direction.
DIAGNOSES
Abnormal PaCO2= respiratory. Abnormal HCO3–= metabolic. If both are abnormal, it is both respiratory and metabolic.
Respiratory Acidosis
Respiratory Alkalosis
Interventions: encourage slow deep breathing; correct underlying condition; provide fluids intravenously; and cor-rect hyperventilation with a non-rebreather mask without oxygen.
Metabolic Acidosis
Diabetic Ketoacidosis (DKA)
Metabolic Alkalosis
This chapter does not replace the electrocardiogram courses or advanced cardiovascular life support certification required to practice in the emergency room. Many nurses find it very helpful to keep an advanced cardiovascular life support manual for study.
Congestive Heart Failure (CHF)
Acute Myocardial Infarction
Arterial Occlusion
Endocarditis
Aortic Injuries
Symptomatic Bradycardia
Supraventricular Tachycardia (SVT)
Some asthma medications, cold medications, and digoxin can also contribute to supraventricular tachycardia. If patient is symptomatic and unstable: expect order to: prepare for immediate synchronized cardioversion (100 y, 200 y, 300 y, 360 y, or biphasic equivalent).
Ventricular Fibrillation or
Pulseless Ventricular Tachycardia
Question: If none of the above interventions work, what are some other causes of ventricular fibrillation. Question: You see ventricular fibrillation on the monitor, but your patient is asymptomatic, sitting up and talking to you.
Pulseless Electrical Activity
Question: What type of electrocardiogram changes would you see in a patient with a potassium level of 7.8. Q: What dose of lidocaine should be given to patients with renal insufficiency, liver insufficiency or elderly patients.
TYPES OF DISASTERS
INTERVENTIONS
Assess the hazards: What are the other possible hazards (for example, downed power lines, blood, smoke, leaking gas lines, bad weather). Assess victims who cannot walk or move as they are more urgent and need assistance.
RADIATION, CHEMICAL, AND BIOLOGICAL EXPOSURES
To remember the appropriate interventions to follow in a disaster, remember memory, DISASTERS, MEASURES and IDME.
Abrin or Ricin
If the poison is inhaled: Within 4 to 8 hours, the patient will experience discomfort; fever; cough; shortness of breath; If poison is swallowed: nausea, vomiting and diarrhea; rectal bleeding; hypotension; gastrointestinal necrosis; and hepatitis.
Anthrax
Interventions: decontamination of the patient with appropriate equipment; use standard precautions; administering fluids intravenously as ordered; and avoid exposure to contaminated materials. Interventions: Anticipate orders to: obtain blood cultures, arrange chest x-ray and CT scan, administer antibiotics such as ciprofloxacin, and use standard precautions.
Botulism
Blister Agent (Mustard Gas)
Brucellosis
Cyanide
Nerve Agents
Plague (Bubonic)
Fever
Radiation
Smallpox
Tularemia
Viral Hemorrhagic Fevers
Cholera (Vibrio cholerae)
Although this chapter should give you a good working knowledge of common forms of disasters and what to do, participating in disaster drills is an essential piece of the puzzle. In most cases, they are not life-threatening. From foreign objects to trauma or infection, this chapter will walk you through the most common ear, nose, and throat emergencies you'll encounter.
DIAGNOSES Foreign Objects
Fill the ear canal with warm water and peroxide solution and leave to soak for 10 minutes. Now that the wax is soft, irrigate the ear canal with a syringe and rest of the water solution.
Acute Otitis Externa (Swimmer’s Ear)
Causes: External ear infections usually occur due to frequent swimming or foreign objects in the ear. When examining the ear in an adult, pull it up and back, in a child under three, pull the ear down and back.
Acute Otitis Media
Ruptured Tympanic Membrane
Interventions: In most small perforations, the eardrum grows back on its own, much like a fingernail grows.
Ménière’s disease
Allergic Rhinitis (Hay Fever)
Epistaxis
Interventions: the patient is seated and leaning forward; press directly on the bridge of the nose; apply ice; prescription drugs (pseudoephedrine); and prepare to cauterize or close your nose. Establish large-bore intravenous access if ordered; have suction and headlamp available; make an appointment for an ear, nose and throat consultation; preparation for the procedure (posterior nasal packing, nasal tampon or cauterization); and monitors level of consciousness, vital signs, pulse oxygen and bleeding.
Nasal Fracture
Signs and symptoms: nosebleed; nasal ecchymosis or edema; nasal airway obstruction; and deformity or tenderness of the nasal bridge. Interventions: control bleeding with direct pressure; apply ice; administer painkillers as prescribed and evaluate effectiveness; and obtain a nasal or facial x-ray.
Sinusitis
If the nasal airways are blocked, the patient will be referred to an ear, nose and throat specialist for repair one week after the swelling subsides.
Pharyngitis/Tonsillitis
Peritonsillar Abscess
Interventions: prepare for incision and drainage of abscess with ear, nose and throat consultant; administer antibiotics and pulsatile oxygen; and monitor the airway. You should now have a basic understanding of the ear, nose, and throat problems seen every day in the emergency room.
DIAGNOSES Edema
Causes: The body's natural response to a severe burn injury is swelling and fluid displacement.
Hyponatremia
Signs and symptoms: irritability; nausea and vomiting; sei - zures; weakness; orthostatic hypotension; headache; tachycardia; lethargy; stomach cramps; and dry oral mucosa. Interventions: anticipate orders to: correct fluid imbalances, intravenously administer normal saline 0.9% or 0.3% if hyponatremia is severe, perform basic metabolic panel and monitor closely.
Hypernatremia
Hypokalemia
Hyperkalemia
As blood sugar falls with insulin therapy, the potassium will move into the cell and the serum potassium level will fall.
Hypocalcemia
Chvostek's sign: Spasm of the facial muscles when the facial nerve tapped in front of the external ear, below the temporal bone. Trousseau's sign: Hand/carpal spasm when inflating the blood pressure cuff above systolic pressure for three minutes.
Hypercalcemia
Interventions: Provide orders for: intravenous saline, cardiac monitoring, intravenous calcium chloride or calcium gluconate, and correction of magnesium deficiency. Interventions: Provide orders to: administer diuretics and 1 to 2 liter bolus of normal saline intravenously, monitor cardiac rhythm, perform a basic metabolic panel, measure magnesium levels, measure intake and output, monitor heart failure, and administer medications (glucocorticoids, calcitonin, phosphate or ethylenediamine tetraacetic acid).
Overhydration
Dehydration
Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) This is a severe state of dehydration as a result of a very high
Expect orders to: start with normal saline intravenous bolus, then change the intravenous fluid to 5% Dextrose 0.45% normal saline (D5 1/2NS) once the blood sugar is less than 300; administer regular insulin at 5 to 10 units of intravenous pressure, followed by a drip of 0.05 units/kg/hour until blood sugar is less than 300, monitor heart rhythm, perform an electrocardiogram, check blood sugar every hour, prepare a complete blood before count, basic metabolic panel, and urinalysis, replace potassium, and prepare for intensive care unit admission. Note the symptom and blood sugar differences between hyperosmolar hyperglycemic nonketotic coma and diabetic ketoacidosis.
NEVER UNDERESTIMATE ABDOMINAL PAIN I once had a female patient come in by ambulance complain-
DIAGNOSES Gastritis
A gastrointestinal cocktail consists of Maalox and belladonna (adding 10 milliliters of viscous lidocaine makes it a super gastrointestinal cocktail.
Gastroenteritis
After that, clear fluids must be introduced in small increments (ice chips) for 24 hours, after which the patient can proceed to full fluids.
Gastroesophageal Reflux Disease (GERD)
Interventions: Anticipate assignments to: administer fluids intravenously, prepare a basic metabolic panel and complete blood count, administer medications (antibiotics, antiparasitics), and provide patient education about clear fluid and BRAT (bananas, rice, applesauce and toast) diet.
Intestinal Obstruction
Signs and symptoms: fever; abdominal distension; nausea and vomiting; rapid onset of abdominal pain; dehydration; Interventions: expect orders to: arrange abdominal CT scan or X-rays, monitor orthostatic vital signs, give nothing by mouth, administer fluids intravenously, use nasogastric tube for gastric decompression and administer antibiotic medication.
Fast facts in a nutshell Tips for nasogastric tube insertion
Appendicitis
Pancreatitis
Interventions: Anticipate orders to: give the patient nothing by mouth (NPO), administer fluids intravenously, prepare a complete blood count, arrange for an abdominal CT scan, administer antibiotics, and prepare for surgery. Interventions: anticipate orders to: administer fluids intravenously, monitor serum amylase, serum lipase, and blood glucose levels, use nasogastric tube for decompression, administer nothing by mouth, administer medications (antacids, anticholinergics, histamine receptor agonists, insulin, analgesics/narcotics), prevent and treat infections, prepare for possible surgery and instruct the patient in diet (low-fat diet, no caffeine and no alcohol).
Cholecystitis
The patient who is actively vomiting cannot drink water until he sees the emergency room provider, in case the patient ends up going to surgery. Murphy's sign is an increased sharp right upper quad abdominal pain that occurs during inspiration when the patient's gallbladder is palpated and the patient is asked to take a deep breath.
GI Bleeding
Interventions: Anticipate commands to: open a large-caliber intravenous access, prepare a complete blood count and coagulation study, arrange a CT scan of the abdomen, insert a nasogastric tube, extract the stomach contents and stool from the guaiac assess, administer fluids intravenously, test blood for type and cross-match, and prepare for possible blood transfusion. However, genitourinary problems, such as testicular torsion, can lead to loss of life or limb if left untreated. This chapter guides you through the genital and urinary tract problems that you often encounter in the emergency room.
Urinary Tract Infection
Pyelonephritis
Renal Calculi
Epididymitis
Testicular Torsion
Signs and symptoms: penile discharge, bacteria in urinalysis, gradual scrotal pain, fever, epididymal swelling, and chills. Signs and symptoms: acute severe testicular pain radiating to the groin or abdomen, nausea and vomiting and elevated/.
Priapism
You should now understand some of the most common problems that bring patients to the emergency room and how to treat them quickly and effectively. The normal physiological changes of the aging process leave patients more vulnerable to disease, injury and complications. Several important body systems also slow down.
Elder Abuse
Falls
Signs and Symptoms: Conflicting accounts describing how an injury occurred; patient is not given the opportunity to speak; Interventions: nothing by mouth; consider cervical injuries and immobilization (rest, ice, splint and height injuries);
Syncope
Temporary, precipitous decrease in cardiac output due to aortic stenosis, mitral valve disease, cardiomyopathy, dysrhythmias and sick sinus syndrome. Hypersensitive carotid sinus due to neck twisting, constriction of collars and drugs (digitalis, propranolol hydrochloride, alpha-methyldopa).
Dementia
Signs and symptoms: alert with impaired orientation; reduced recent memory; impoverished thinking; difficulty finding words; confused speech; and poor sleep. Interventions: provide a safe environment; put the bed in a low locked position; keep a close eye on the patient (place close to nursing station); and assess whether there are new causes of confusion.
Alzheimer’s Disease
Pneumonia
Urosepsis
Age-related physiological changes in elderly patients will affect their condition and may lead to complications. If the triage screening is positive, follow your facility protocol; this usually requires some form of mask and isolation.
DIAGNOSES Meningitis
Anticipate the following orders: acetaminophen/ibuprofen for fever, monitor vital signs, prepare a complete blood count and blood culture, and prepare for lumbar puncture. Bacterial meningitis shows an elevated white blood cell (WBC) count greater than 1000 cells per mm3 and low glucose in the cerebral spinal fluid.
HIV/AIDS
We do not perform routine HIV testing in the emergency room because we cannot provide follow-up care.
Hepatitis
Cellulitis/Abscess/MRSA
Febrile Neutropenia
Tick-Borne Illnesses
Signs and symptoms: high fever; recent tick bite 2 to 14 days previously; sore throat; headache; nausea and vomiting; fatigue;. For easy tick removal, dab some petroleum jelly on the area before pulling on the main part.
Toxic Shock Syndrome
Includes sudden high fever; hypotension; headache; confusion; tachycardia; nausea, vomiting and diarrhea; sunburn-like rash; fatigue; and seizures.
Tuberculosis
Just in the last 10 years, the way we deal with mental health emergencies has changed dramatically. For example, nurses automatically placed suicidal patients in seclusion "for their own protection" and used restraints more freely. Mental health patients can sometimes be difficult to treat, especially when they engage in disruptive behavior.
DIAGNOSES Anxiety
Posttraumatic Stress Disorder
Depression
Suicide
Violent or Aggressive Behavior
Psychosis
Manic Behavior
You should now have a better understanding of mental health cases and how to deal with them. From sad and suicidal patients to loud and schizophrenic patients wearing lampshades on their heads, you never know what kind of mental health challenge you'll face next in the emergency room.
PLAN FOR THE WORST, HOPE FOR THE BEST I will never forget a patient who took me by surprise. He came
PLAN FOR THE WORST, HOPE FOR THE BEST I will never forget a patient who surprised me.
Stroke (Cerebrovascular Accident)
Signs and Symptoms: Symptoms vary in location, extent, and duration, lasting less than 24 hours without permanent neurologic deficit. Question: The patient claims that this is the worst headache of his life, he has nausea and vomiting; photosensitivity;
Seizures
The patient keeps having one attack after another, so that it seems like one long attack. If it is a pseudoseizure, the patient will suddenly become alert and focus on person, place and time.
Bell’s Palsy
Myasthenia Gravis
Multiple Sclerosis
Cluster Headache
The Glasgow Coma Scale (Table 12.1) assesses impaired consciousness by assessing the patient's eye movement, body movement, and verbal responses. Thus, the nurse must be sure to document a complete and accurate assessment and a secondary assessment to locate the source of the patient's complaint.
DIAGNOSES Endometriosis
Bartholin’s Cyst
Vaginitis
Pelvic Inflammatory Disease
Interventions: prepare for pelvic examination by collecting culture samples; as ordered, administer medication according to offending organism, pelvic rest, and patient teaching. Signs and symptoms: fever; pain in the lower abdomen with rebound sensitivity; irregular menstrual cycle; foul-smelling vaginal discharge; inflammation of the cervix; "PID mix", change in gait due to pain; elevated white blood cell count; and severe pain during pelvic examination.
Spontaneous Abortion (Miscarriage)
Light vaginal Light vaginal Severe vaginal Dirty vaginal Light vaginal bleeding; mild bleeding; mild bleeding and discharge and hemorrhage; closed uterine spasms; uterine cramps; clots; moderate bleeding; cervix open and closed closed cervical cramps; cramps; fever; ing; and no fetal cervical opening; opening; and no open cervical and open heartbeat or extrauterine intrauterine orifice; and vical opening. Pelvic examination and Pelvic examination and Pelvic examination and Pelvic examination and Pelvic examination and pelvic ultra- pelvic ultra- pelvic ultra- pelvic ultra- pelvic ultrasound; RhoGAM sound; RhoGAM sound; RhoGAM sound; blood sound; coagulation injection if Rh injection if Rh is an injection if Rh is a culture; intralation studies;
Ectopic Pregnancy
Placenta Previa
Abruptio placentae
Pregnancy-Induced Hypertension (Pre-eclampsia) Pregnancy-induced hypertension is diagnosed hypertension
Eclampsia
Prolapsed Cord
Signs and Symptoms: A woman in active labor with the umbilical cord exiting through the vaginal canal ahead of the baby. Manual pressure can be applied to the baby's head by gently pushing the finger upward to relieve pressure on the umbilical cord.
Trauma During Pregnancy
CT scan, perform coagulation studies, prepare a complete blood count, blood type and control, arrange for a pelvic exam, access breath sounds for pulmonary edema, prepare for blood transfusion, and prepare for emergency cesarean section.
Emergency Delivery
Ocular Emergencies
As a nurse, you must be able to differentiate between non-urgent and emergent eye complaints. This chapter will guide you through the different types of eye emergencies and teach you the manifestations and interventions for each. The providers you work with will expect a visual acuity on all eye complaints.
Central Retinal Artery Occlusion
Interventions: check the patient's visual acuity; get equipment for eye examination; anticipate orders to: obtain intravenous access, administer vasodilators (eg, intravenous nitroglycerin) and anticoagulants, arrange ophthalmology consultation, and prepare for surgery.
Glaucoma
Corneal Abrasions
Detached Retina
Conjunctivitis/Pink Eye
Penetrating Trauma
Blunt Trauma Blow-Out Fractures This is a fracture of the orbital floor
Hyphema
Chemical Burns
Orthopedic and
You will certainly see all kinds of orthopedic and wound emergencies in the emergency room. This chapter provides a brief overview of the various orthopedic and wound care emergencies you may encounter in the emergency room and how to manage them.
DIAGNOSES Strains
Sprains
Fractures
Interventions: immobilize; assist in applying traction for femur fracture; cover open fractures with sterile saline-soaked dressing; (PRICE) Protect (splint, cast, sling) Rest, Ice, Compression (as wrap), Elevate; X-ray; no weight bearing (crutches); prepare for possible closed reduction;. Question: What other X-ray should be ordered for the patient who has bilateral heel fractures after falling 13′.
Dislocations and Subluxations
Amputation
Compartment Syndrome
Lacerations
Q: When preparing for suture repair of the ear, nose, penis, fingers, or toes, should you use lidocaine with epinephrine?
Burns
You now have a better understanding of orthopedic and wound care emergencies, their symptoms and treatments. Be sure to familiarize yourself with the orthopedic and wound care supplies at your local facility.
Fever
