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Emergency Nursing & Mass Casualty Priorities

Emergency Nursing & Mass Casualty Priorities. Keith Rischer RN, MA, CEN. Todays Objectives. Identify the core competencies needed to function in emergency setting Explain the different roles of the interdisciplinary team Describe the triage process

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Emergency Nursing & Mass Casualty Priorities

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  1. Emergency Nursing &Mass Casualty Priorities Keith Rischer RN, MA, CEN

  2. Todays Objectives • Identify the core competencies needed to function in emergency setting • Explain the different roles of the interdisciplinary team • Describe the triage process • Triage different clients into emergent, urgent, and nonurgent categories • Identify nursing assessment “red flags”regarding chief complaint • Identify the role of the primary & secondary survey • Contrast triage process under usual ED context w/triage in mass casualty

  3. Emergency Department Environment Characterized by: • Rapid change • Med errors • Multispecialty care • Crowded, noisy conditions • Hostile behavior • Staff safety • Crucial communications • EMS • Complex age and demographic range of clients

  4. Frequent Fliers…Problem • 1993-2006 • ED visits increased 26% to 114,000,000 annually in US • FF represent small %, consume disproportionate amt. of health care dollars • Contributes to overcrowding • 5% of all ED pts. • 1/3 ED visits non-urgent-could be provided in other settings

  5. Frequent Fliers…Demographics • 35 yr old Caucasian female • Single, unemployed • Has primary MD and public/private health insurance • Chronic medical conditions w/pain of same type the most common CC • Non-narcotic approaches to pain utilized • ED visits decr. From 19 to 7 annually

  6. Prehospital care providers Paramedic Emergency Medical Technician (EMT) Emergency medicine physician Registered Nurse BLS ACLS PALS TNCC Certification in Emergency Nursing (CEN) Support staff Emergency Tech Unit Support Sexual assault nurse examiners Psychiatric Crisis Inpatient nursing staff Interdisciplinary Team Members

  7. Triage • Brief clinical assessment to determine time, order, and sequence clients are seen • Quickly identify emergent/life threatening conditions as well as SUBTLE manifestations • highest acuity needs receive the soonest evaluation, treatment, and prioritized resource utilization • Triage nurse in the emergency care system performs rapid assessment to determine triage priority by category: • Emergent triage • Urgent triage • Nonurgent triage

  8. Triage Interview • Assess carefully • “What brought you to the ER today?” • Use all senses • Visual • Smell • Auditory • Tactile/touch • Intuition

  9. ED Assessment: Airway/Breathing Red Flags • Obvious resp. distress • Tachypnea • O2 sats <90% • Hx of COPD, asthma or croup • Recent surgery or immobility • Drooling-SOB • Stridor or barky cough

  10. ED Assessment:Chest Pain Red Flags • Male >30 yrs…>35 yrs female or post menopause • High risk factors…hx CAD, DM, high cholesterol, HTN • Chest pain • Cardiac • Quality • Radiation • Severity • timing • Non-cardiac • Quality • Radiation • Severity • timing

  11. ED Assessment : Women & CAD • #1 killer of women…more than #2-14 combined • Develop 10 yrs later than men on avg. • Protective effects estrogen • Atypical presentations • Mortality rate 2x higher than men • Unrecognized sx/atypical presentation • Less likely to be dx w/AMI • Do not receive early & aggressive tx

  12. ED Assessment: Headache Red Flags • Sudden onset-severe • Syncopal or neuro deficits present • HA w/fever • Recent head trauma • Coumadin • Distinctly different from previous hx • “worst headache I’ve ever had”

  13. ED Assessment:Abdominal Pain Red Flags • Blood in emesis or stool • Persistent N&V &D • >18 hours older than 6 yrs • >12 hours if less than 6 yrs • Sudden • AAA • Bowel obstruction • Renal calculi • Chole/pancreatitis • Gradual • Appe • Constipation • UTI • Palpation or any body movement worsens

  14. ED Assessment: Pearls Across the Lifespan • Trauma • MECHANISM OF INJURY • Pediatric • Child abuse • Larger tongue/smaller trachea • Dehydration-lips/mucous membranes/no tears • Temp >100.4 in child <12 weeks • Elderly • Elder abuse/neglect • Use other family members to clarify CC • Slow down to sort out • Hypothermia-sepsis • Atypical CP

  15. Triage How do you classify & prioritize the following? • 28 yr male w/laceration-bleeding controlled • 22 yr female w/lower abd pain & heavy vaginal bleeding • 22 yr female w/lower gradual abd pain 8/10 only • 45yr female w/CP last 2 hours-hx DMII • 20 yr male w/CP-worsens w/deep insp. • 78 yr female w/HA & brief syncopal episode • 82 yr male w/abd pain-distended 10/10

  16. Primary & Secondary Survey • Primary • (A) Airway/cervical spine • (B) Breathing • (C) Circulation • (D) Disability • Glascow coma scale • AVPU…LOC assessment • (E) Exposure • Secondary

  17. Care of the Emergency Department Client • Nursing assessment • Triage • Chief complaint • VS • PMH • Primary RN once in room • Primary/secondary assessment • Initiate standing orders • Delegate to ED tech prn • Physician assessment • Disposition • Client and family health teaching

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