NCLEX: Emergency Nursing

Terms you’ll need to understand:
Biological weapons
Chemical agent
Emergent
Non-urgent
Urgent

Nursing skills you’ll need to master:
Performing a head-to-toe assessment
Performing cardiopulmonary resuscitation
Administering medication
Administering intravenous fluids
Administering blood
Applying splints and manual traction
Performing dressing changes

Nursing in the emergency department can be thought of as nursing in the fast lane. Unlike the routine of unit nursing, emergency nursing requires the nurse to respond to diverse conditions with much versatility. Many emergency situations confront the client and his family with fears of death or disability. Therefore, the ER nurse must assist with stabilizing the client’s physical condition while providing emotional support to both the client and his family during a time of crisis. Faced with life and death on a daily basis, emergency nursing is not for everyone.
A primary principle in providing emergency care is triage, or the sorting of clients into one of three categories:
- Emergent
- Urgent
- Non-urgent

Using this system, the clients with the most life-threatening conditions are cared for first. This is different from the triage applied in disasters or in field situations where scarce resources are allocated to care for the greatest number.
In this guide you will review some of the most common conditions cared for in the emergency department. You will not spend time on the conditions that were covered in previous guides on Fatskills. Instead, you will focus on the ABCDs of emergency care and the treatment of trauma, poisonings, and poisonous bites. Finally, you will review the care of clients who are victims of radiation accidents as well as chemical agents and biological weapons.

The ABCDs of Emergency Care
Initial management of the client in the emergency department is based the ABCD assessment: airway, breathing, circulation, and deficits. Airway obstruction, whether complete or partial, requires prompt intervention. In the case of complete obstruction, appropriate intervention is needed to prevent permanent brain damage or even death. After the airway has been secured, the nurse assesses the client’s breathing to determine whether the client’s respiratory effort is sufficient or whether assisted ventilation and oxygen will be needed. Evaluation of the client’s circulation and control of bleeding are next in the order of trauma assessment. Only relief of airway obstruction and care of sucking chest wounds take priority over the immediate control of bleeding. With airway, breathing, and circulation under control, the nurse turns her attention to assessing for deficits. These include additional injuries such as fractures, burns, wounds, and neurological injuries. Each of these areas is covered in greater detail as they form the basis for trauma interventions.

Airway
The first consideration is to find out whether the airway is patent. Are there signs of partial obstruction or complete obstruction? Signs of partial obstruction include noisy breathing and coughing, and signs of complete obstruction include inability to breathe, inability to talk, inability to cough, and clutching the throat. Death from complete airway obstruction can result in as little as 3–5 minutes due to hypoxia.
Clients who need airway management include those with scores of less than 8 on the Glasgow coma scale, those with maxiofacial injuries, those who have aspirated, and those with inhalation injuries from burns. More information on inhalation injuries from burns can be found in Chapter 7.
Interventions are aimed at maintaining a patent airway. A client with partial obstruction of the airway should be encouraged to cough forcefully. In the event that the airway is completely obstructed, it can be opened using the head-tilt chin lift maneuver or the jaw-thrust maneuver.
After the airway is open, it will be maintained by an oropharyngeal or nasopharyngeal airway or an endotracheal tube.
You might want to refer to the nursing textbooks for guidelines for managing a foreign body airway obstruction and performing cardiopulmonary resuscitation.

Always provide C spine immobilization before opening the airway of any client with undetermined or suspected neck injuries. The jaw–thrust maneuver should be used for a victim with suspected neck injury because it can be done without extending the neck.

Breathing
The next consideration is to find out whether the rate and depth of respirations are adequate. The normal respiratory rate for adults is 12–20 breaths per minute; for children it’s 15–30 breaths per minute; and for infants it’s 28–50 breaths per minute. Lung sounds should be clear and equal bilaterally.
Inadequate breathing in the adult is evident in slowed (less than 8 breaths per minute) or rapid (greater than 24 breaths per minute) respirations. Other signs of inadequate respirations are labored breathing, intercostal and suprasternal retractions, changes in lung sounds, asymmetry of the chest wall, and cyanosis.
Interventions for ineffective breathing patterns are aimed at providing relief of symptoms. These interventions include maintaining a patent airway and providing supplemental oxygen. High-concentration oxygen is used in any cardiac or respiratory arrest situation.

Circulation
Next you must find out whether circulation is adequate. Are there signs of bleeding? The nurse should assess the rate, rhythm, and strength of the pulse and obtain an admission blood pressure. If the radial pulse can be felt, the systolic blood pressure is usually above 80 mm Hg. The nurse should check for capillary refill. If capillary refill is adequate, the area being assessed will return to normal color within 2–3 seconds after blanching. If the area remains white or blue, the area is not receiving adequate circulation.
Circulation is obviously affected by blood loss. The nurse can assess for external bleeding by doing a blood sweep. This is carried out by running a gloved hand from head to toe, pausing periodically to see whether the glove is bloody.
External bleeding can be controlled by applying direct pressure to the area, elevating or immobilizing the affected extremities, or applying direct pressure over arterial pressure points. In most cases bleeding can be stopped by direct pressure over the artery, unless a major artery has been severed.
Tourniquets or inflated blood pressure cuffs are applied to an extremity only if hemorrhage cannot be controlled by direct pressure. The tourniquet should be applied just proximal to the wound and only tight enough to control arterial blood loss. The tourniquet should be loosened periodically to prevent neurovascular damage. If there is no further arterial bleeding, the tourniquet should be removed and a pressure dressing applied.

Interventions for inadequate circulation and hypovolemic shock are aimed at restoring adequate circulation and maintaining the blood pressure within normal limits. Infusions of warmed Lactated Ringers are started in at least two veins using a large-bore catheter (14- or 16-guage). IV access, using the upper and lower extremities, is necessary if there is bleeding from a major vessel in the chest or abdomen. Infusion of Lactated Ringers solution helps restore circulation and allows time for blood typing and screening. The restoration of circulating blood volume depends on blood replacement.
Additional interventions for a client with hypovolemic shock include the insertion of a CVP line, insertion of an indwelling urinary catheter, monitoring of arterial blood gases, monitoring of vital signs, maintaining normal body temperature, and treating acid base disturbances. Lactic acidosis, a common side effect of hemorrhage and injury, is associated with poor cardiac function.
Resuscitative efforts continue until the client has a serum lactic acid lower than 2.5 mmol/L within 24 hours after the injury and there are no further signs of hemorrhage.

Deficits
Lastly, you need to ascertain the client’s mental status. Are there changes in the client’s level of consciousness? Deficits in these areas can reflect neurological injury.
The nurse can test for deficits by assessing the client’s responsiveness and orientation. These assessments can be done quickly. To test for responsiveness, the nurse notes the following key points, which are sometimes referred to as AVPU:
- Alertness—Is the client aware of his surroundings and circumstances?

Does the client know his name? Is he able to state the year, month, and day? Does he know what happened and where he is?
- Verbal stimuli—Does the client respond to questions asked by the examiner? Can he state his name? Can he identify common objects? Can he respond to simple requests? If the client can respond appropriately to what he is asked, he is said to be alert and oriented.
- Pain—Is the client aware of painful stimuli? Can he identify where pain is located? Can he describe the pain? Can he assess the pain using a pain scale?
- Unresponsiveness—Does the client respond to any stimuli?

The nurse can test the client’s orientation by checking the client’s awareness of person, place, time, common objects, and event. Questions about his name; where he is; the day, month, and year; and what happened help establish that the client is oriented. If the client can answer all these questions and is alert, he is determined to be alert and fully oriented.
After checking for responsiveness and orientation, the nurse assesses the pupils for size, shape, equality, and reaction to light. Pupillary changes should be reported immediately because they indicate changes in neurological status.

Obtaining Client Information
After airway, breathing, circulation, and deficits have been assessed and stabilized, the nurse focuses on obtaining a history of the current condition as well as significant information regarding medications, allergies, and past medical history. The emergency room staff then focuses on the client’s reason for seeking treatment.

Trauma
Trauma is defined as unintentional or intentional injury to the body, and it is the number one cause of death in persons under 44 years of age. Most traumatic injuries are the result of motor vehicle accidents (MVAs). Areas affected most often in MVAs are the head, chest, and abdomen. Other traumatic injuries include suicides, homicides, and physical assaults.
After performing the ABCD interventions, the nurse assesses for signs of traumatic injury. Rapid trauma assessment, using a head-to-toe approach, can be done using the mnemonic DCAP – BTLS. The nurse assesses the client for the presence of
- Deformities
- Contusions
- Abrasions
- Punctures or penetrations
- Burns
- Tenderness
- Lacerations
- Swelling

Head Injuries
Head injuries account for more than one third of the injuries sustained in MVAs. Other sources of head injury include falls and sports injuries. Head injuries are classified as primary brain injuries (open or closed head trauma) and secondary brain injuries (the result of the primary injury). Examples of primary brain injuries are fractures and penetrating injury. Examples of secondary brain injuries are increased intracranial pressure, hemorrhage, and loss of autoregulation. Interventions are focused on assessing and managing increased intracranial pressure, assessing the level of consciousness using the Glasgow coma scale, controlling seizures, and minimizing neurological deficits. 
Coup and contrecoup injuries affect different portions of the brain. Coup (site of impact) injuries occur in the frontal area of the brain. Contrecoup injuries occur in the frontal and temporal areas of the brain.

The use of opiates is contraindicated for a client with a head injury because they cause central nervous system depression.

Chest Injuries
Chest injuries account for about one fourth of the injuries sustained in motor vehicle accidents. Trauma to the head and chest is drastically reduced by the proper use of seat belts and air bags as well as child safety restraints. Chest injuries include pulmonary and cardiac contusions, pericardial tamponade, fractured ribs, flail chest, pneumothorax, hemothorax, and ruptured diaphragm. Interventions include maintaining adequate respirations, controlling hemorrhage, and treatment of the specific injury. For example, pneumothorax and hemothorax are treated with the insertion of chest tubes and closed chest drainage.
Flail chest should be suspected in clients with multiple rib fractures, scapular fractures, and pulmonary contusion. Unequal chest movement characterizes flail chest.

Abdominal Injuries
Abdominal injuries account for about one fourth of the injuries sustained in MVAs. Abdominal injuries can be blunt injuries, (such as from seat belts) or penetrating injuries (such as from gunshots or stab wounds). Penetrating injuries can damage hollow structures, particularly the small bowel, or solid organs. The most frequently damaged solid organ is the liver.
The major cause of death from abdominal trauma is hemorrhage. An assessment for abdominal injury should include inspection of the anterior abdomen, flanks, back, genitalia, and rectum. In the case of intra-abdominal injury, blood tends to collect in these areas. Rectal and vaginal examination is performed to determine injuries that might have occurred to the pelvis, bladder, or intestines.
Assessment of abdominal injury begins with obtaining a history of the mechanism of injury. Was the injury penetrating, as in the case of a gunshot, or was it blunt, as in the case of a blow to the abdomen? The abdomen is then inspected for obvious signs of injury. Entrance and exit wounds are noted, as are bruises and characteristic markings such as those left by seatbelts. The examiner auscultates for the presence of bowel sounds and records findings for comparison with later assessments. Areas of progressive distention, involuntary guarding, and tenderness are noted. The nurse should assess the chest for signs of injury that might accompany abdominal trauma.
The incidence of complications from blunt abdominal trauma is greater than from penetrating injuries. This is especially true when there is blunt injury to the liver, kidneys, spleen, or blood vessels that can result in massive blood loss that can go undetected for some time.
The nurse should be familiar with indications of intra-abdominal bleeding.
Ecchymosis around the umbilicus (Cullen’s sign)and ecchymosis on either flank (Turner’s sign) indicate retroperitoneal bleeding into the abdominal wall.

The nurse should be familiar with indications of damage to the spleen. With the client lying on the left side, the right flank is percussed. Resonance over the right flank (Ballance’s sign) indicates rupture of the spleen. Pain in the left shoulder (Kehr’s sign) is seen in a client with a ruptured spleen; pain in the right shoulder indicates lacerations of the liver.

Additional indications of abdominal trauma include the absence of bowel sounds, progressive abdominal distention, abdominal pain and tenderness, and evisceration.

Cover abdominal contents with sterile normal saline-soaked gauze. Do not try to return the abdominal contents to the abdominal cavity.

Interventions for the client with abdominal injuries include the insertion of two large-bore IV catheters for delivering fluid and blood replacement, cardiopulmonary monitoring, insertion of an indwelling urinary catheter, and insertion of a nasogastric tube.
You should not insert a nasogastric tube if there is a suspected skull fracture.

The use of opiates for pain control is contraindicated because they can mask important signs and symptoms.

Documenting and Protecting Forensic Evidence
It is essential that the nurse provide accurate documentation and protection of forensic evidence when caring for trauma clients. When removing clothing, the nurse should avoid cutting through any tears, holes, blood stains, or dirt that might be used as evidence. Each piece of clothing should be labeled and placed in an individual paper bag before giving it to the police. The name of the officer, the date, and the time should be documented in the client’s chart. Valuables should be placed in the hospital safe or given to a family member with appropriate documentation.
If homicide is suspected, the body of the deceased will be examined by the medical examiner or coroner. All tubes and lines should remain in place. The client’s hands should be covered with paper bags to protect evidence that might be on the hands or under the nails. Swabs will be used to obtain tissue samples from beneath the nails. The client’s wounds and clothing will also be photographed.
Procedures for protecting forensic evidence are the same for physical and sexual assault.

In cases of suspected sexual assault, the client is instructed not to shower, bathe, or change clothing. A rape trauma kit is used to collect forensic evidence. Swabs are used to obtain tissue specimens from the hands and fingernails. Specimens should be carefully labeled and protected as potential evidence. Photographs of wounds and clothing should include one with a reference ruler and one without a ruler.

Poisoning
Poisoning results from the ingestion, inhalation, or absorption of agents that cause chemical actions that injure the body. Emergency management of the client includes
- Removing or inactivating the poison
- Providing supportive care to maintain vital organ systems
- Administering specific antidotes
- Initiating treatment to facilitate the excretion of the absorbed poison

The American Association of Poison Control Centers has a website at www.aapcc.org for further information.
Vomiting is never induced in a client who has ingested a corrosive or petroleum distillates.
Psychiatric consultation should be obtained if the poisoning is determined to be a suicide attempt.

Management of clients with poisonings related to lead, iron, aspirin, and acetaminophen can be reviewed in Caring for the Pediatric
Client.' Treatment of clients with chemical injuries and those with carbon monoxide poisoning was covered earlier, and interventions for food poisoning were covered here. Treatment of drug overdoses such as narcotics and barbiturates were covered in, 'Caring for the Client with Psychiatric Disorders.' You might want to review those chapters for comparison with the overall management of poisoning.

Poisonous Stings and Bites
These are mainly produced by hymenopterans (bees, yellow jackets, wasps, hornets, and fire ants) or by venomous snakes (pit vipers) Injected poisons result in clinical manifestations that range from generalized redness, itching, and anxiety to bronchospasm, shock, and death. Snake venom can affect multiple organ systems—especially the cardiovascular, respiratory, and neurological systems.
 

Management of a client with a sting includes removing the stinger and washing the area with soap and water. The client should be discouraged from scratching the affected area because scratching releases histamine. Oral antihistamines and analgesics lessen pain and itching.
In cases of anaphylaxis or severe allergic reaction, aqueous epinephrine is administered subcutaneously and the injection site is massaged to speed drug absorption. Additional interventions focus on maintaining the client’s respiratory and cardiovascular function. Desensitization is recommended for clients with a history of significant local or systemic reactions to stings.

The management of venomous snake bites is a medical emergency. The client should be instructed to lie down. Constricting items such as rings are removed, and the affected area is immobilized below the level of the heart.
If the snake is dead, it should be brought to the emergency room to help identify the species.

Interventions include determining the severity of poisonous effects; obtaining vital signs; measuring the circumference of the affected extremity; and obtaining laboratory specimens for complete blood count, urinalysis, and clotting studies. In cases of envenomation—the injection of venom—antivenin is administered. Antivenin is most effective when given within 12 hours of the snake bite.
Corticosteroids are contraindicated in the first 6–8 hours after the bite because they can interfere with the action of the antivenin.

A test dose of antivenin, using the skin test or eye test, should be done before administering the medication.

The most common cause of allergic reaction to antivenin is too rapid infusion. Allergic reactions include feelings of facial fullness, itching, rash, and apprehension. These symptoms can be followed by tachycardia, dyspnea, hypotension, and shock. In case of allergic reaction, the antivenin should be discontinued immediately, followed by the intravenous administration of diphenhydramine.

Bioterrorism
The threat of bioterrorism has brought with it new concerns and challenges for emergency personnel. Acts of bioterrorism are carried out using biological and chemical agents that are capable of disabling or killing thousands of people in a relatively short period of time. The unique nature of biological and chemical weapons is extremely frightening. These substances can be liquid or dry; dispensed in food and water supplies; vaporized for inhalation; spread by direct contact; and spread by vectors, including animals, insects, and persons.
Two biological agents most likely to be used as weapons are anthrax and smallpox.

Chemical and Biological Agents
Chemical agents produce effects that are more apparent and occur more quickly than biological agents. Chemical agents are classified as nerve agents, blood agents, vesicants, and pulmonary agents. Some chemical agents, such as chlorine, phosgene, and cyanide, are widely used in industry; therefore, they are widely accessible.

Chemical and Biological Agents Symptoms and Treatments:










Nuclear Warfare
Another source of terrorist activity involves the threat of nuclear warfare.
Radioactive material includes not only nuclear weapons, but also radioactive samples of plutonium and uranium as well as medical supplies such as those used in cancer treatments. Exposure of a large number of people could be accomplished by placing this radioactive material in a public place.
The following list highlights three types of radiation injury that can occur:
- External irradiation—The client does not require special isolation or decontamination.
- Contamination—The client requires immediate medical management to prevent incorporation.
- Incorporation—The client requires immediate medical management because the cells, tissues, and susceptible organs (kidneys, bones, liver, and thyroid) have taken up the radioactive material.
Management of the client follows the hospital and countrywide guidelines for radiation disasters. These guidelines are very specific regarding decontamination and treatment of the injured. Staff is required to wear protective clothing, including two pairs of gloves, masks, caps, goggles, and booties.
Dosimetry badges should be worn by all caregivers participating in the client’s care.
should take place outside the hospital whenever possible.
Clothing should be removed, double bagged, and placed in a plastic container outside the facility. In a case where decontamination is delayed until hospital arrival, the client should be assessed with the radiation survey meter to determine external contamination. The client is taken to an area away from the ER equipped with a shower, collection pool, tarp, and collection containers for clothing and personal items. Additional washings should continue until the client is free from contamination.
Internal contamination or incorporation requires the use of cathartics and gastric lavage with chelating agents. These agents bind with the radioactive substances, which are then excreted in the urine, feces, and vomitus. Samples are obtained to determine the effectiveness of internal decontamination.
Acute radiation syndrome (ARS) can occur after a radiation injury. The development of ARS is dependent on the dose of radiation rather than the source, and symptoms vary according to the body system. Effects on the hematopoietic system are evident in the decreased number of white blood cells, red blood cells, and platelets that make the client vulnerable to infection and bleeding. Neurological effects include headache, nausea, and vomiting. Radiation of the skin produces redness, desquamation, and (in some instances) necrosis.

Triage Categories for Disaster Victims
A final point should be made regarding the care of clients in disasters such as those posed by terrorist acts or nuclear accidents. In disasters, the rules of hospital triage no longer apply. Faced with hundreds and possibly thousands of casualties, caregivers must use the color-coding system developed by the North Atlantic Treaty Organization (NATO).

NATO Triage Color Codings (Triage categories for disaster situations)



Diagnostic Tests for Review
Diagnostic tests carried out for clients in the ER are mostly the same as those used for hospitalized clients. In some instances, such as poisonings, more specific tests such as toxicology screens might be ordered. The nurse should be familiar with the tests and diagnostic procedures routinely performed in the ER. These tests include
- Bleeding tests (PT, PTT, INR)
- CBC
- Chest x-ray
- Complete metabolic panel
- CT scan
- Liver profile
- MRI
- Urinalysis

Pharmacology Categories for Review
Categories of medications administered in the ER are much the same as for clients admitted to medical surgical units. These categories include
- Analgesics
- Antiarrhytmics
- Antibiotics
- Anticonvulsants
- Antiemetics
- Antihistamines
- Anxiolytics
- Bronchodilators
- Cardiotonics
- Emetics
- Local anesthetics
- Vasoconstrictors