Caring for the Patient in the Emergency Department

Renee Semonin-Holleran

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CHAPTER

Outcome-Based Learning Objectives

After studying this chapter, the learner will be able to: 1. Explain the practice of emergency nursing. 2. Differentiate among the various components of the triage process and determine each components relevance. 3. Compare and contrast patient priority categories. 4. Explain the legal issues related to the practice of emergency nursing. 5. Describe preparation for emergency nursing practice.

Emergency nursing is described as the care of individuals of all ages who have perceived or actual physical or emotional alterations of health that have not been diagnosed or require further interventions. Emergency nursing care is episodic, may involve primary as well as secondary and tertiary care, and is usually acute or critical in nature (Bonalumi & King, 2007; MacPhail, 2003). Emergency nursing involves care in a variety of areas including the prehospital and hospital environments. The Emergency Nurses Association (ENA) states that emergency nursing provides care that ranges from birth to death. Emergency nursing also includes injury prevention, womens health, disease management, and providing care aimed at managing life- and limb-threatening emergencies. Unique to emergency nursing practice is the application of the nursing process to patients of all ages who require stabilization and/or resuscitation for a variety of illnesses and injuries (ENA, 1999).

History
Florence Nightingale has long been associated with the origins of emergency nursing when she took nurses out to the field to provide care to wounded soldiers. The care she and her fellow nurses provided on the battlefields demonstrated the value of rapid management of acute patients. As hospitals developed, care that had generally been done by physicians, nurses, or

even family members in patients homes was redirected to the hospital. Emergency nursing and emergency medicine have developed into a specialty during the past 50 years. Care provided to soldiers during the Korean and Vietnam wars demonstrated that rapid and acute care could make a difference in patient outcomes. However, the departments in hospitals that were dedicated to the emergent care of patients were limited. Oftentimes, the emergency department was one room staffed by a nurse who was generally called down from another floor or by the hospital nursing supervisor. When emergency medicine was recognized as a specialty in the late 1970s, it quickly became one of the fastest growing medical fields. The Emergency Department Nurses Association was established in 1970 by Anita Dorr (Buffalo, New York) and Judith Kelleher (Downey, California). The associations name was later changed to the Emergency Nurses Association. Initially, ENA and the American College of Emergency Physicians shared the same offices. As both associations grew, so did issues between the two groups (Schriver, Talmadge, Chuong, & Hedges, 2003). However, the important issues that face both emergency nurses and physicians have brought both organizations together. Today emergency medicine and emergency nursing both have specific curricula and clinical requirements. Each also has specialized examinations. For emergency nursing that is the Certified Emergency Nurse exam or
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Disaster, Emergency, and Trauma Nursing recognized many of the challenges that are being faced today by the emergency medical system and its nurses and physicians. Overcrowding, ambulance diversions, shortage of on-call specialists, lack of emergency preparedness, and deficiencies in pediatric emergency care are some of the issues that were identified. The recommendations summarized in the National Guidelines box have been made to improve emergency care systems in the United States using a multifaceted, multiorganizational approach. The IOM study and these proposals will provide a framework for the delivery of emergency care in the years to come.

the CEN. For information regarding the exam, go to the Emergency Nurses Association web site.

The Role of the Emergency Department

In 2006, more than 119 million visits were made to emergency departments in the United States (National Center for Health Statistics, 2007). Emergency department visits continue to grow, yet emergency departments are closing, initiating ambulance diversions, increasing waiting times, and boarding patients who are critically ill and injured. This overcrowding in emergency departments is occurring because of decreasing numbers of doctors and nurses and limited hospital beds (Institute of Medicine [IOM], 2006; Reeder & Garrison, 2001). Emergency departments have become the source of care for many types of patients, but particularly for patients who are poor and uninsured. Emergency departments are open 24 hours a day, 7 days a week. Additionally, because of the Emergency Medical Transport and Active Labor Act (discussed later in this chapter), emergency departments cannot refuse to provide a medical screening examination and stabilizing care when patients present for care. The increase in uninsured patients, the open access, and the ability to provide 24-hour-a-day care have stressed the capacity of emergency departments. Emergency departments must also deal with the challenges of providing care to a more and more diverse patient population. Examples of the types of patients who utilize the emergency department to supply their primary care include illegal immigrants, prisoners, and homeless and underinsured patients. Additionally, the population has become more diverse culturally and care of these patients requires that emergency nurses and physicians be culturally competent (see the Cultural Considerations box). In the United States, the emergency department has become the single point of universal access to health care. This will continue to be an important challenge in the practice of emergency nursing, and one for which nursing will need to provide a leadership role in order to solve.

Emergency Nursing Roles

The role of the emergency nurse is many and varied. Emergency nursing can be practiced both inside and outside of the hospital. In addition, emergency nurses may be involved in numerous functions within the emergency department including education, prevention, and research. Chart 731 summarizes some of the roles of emergency nurses.

Specialty Roles in Emergency Nursing

Emergency care requires a team approach and involves basic and advanced providers. As emergency nursing has evolved, both specialty and advanced practice roles have developed. Many of these roles are governed by specific agencies (e.g., state boards of nursing practice) or national associations (e.g., Sexual Assault Nurse Examiners). Chart 732 provides a summary of some of these specialty roles.

Triage
The word triage is derived from a French word that means to sort. In emergency care, triage is a process that is used to determine the severity of a patients illness or injury. Medical triage evolved during war where battles resulted in lots of casualties and resources were limited. Napoleons surgeon, Dominique Jean Larrey, has been credited with initiating this concept on the battlefield. Florence Nightingale used the triage concept during the Crimean War. She went out after the daily fighting and sorted out those who might or might not survive and provided much needed care (Thomas, Bernardo, & Herman, 2003). During the 20th century, battlefield triage consisted of a primary assessment and the performance of critical interventions such as control of bleeding and then rapid transport to MASH units. During the Korean and Vietnam wars, helicopter transport was introduced to enhance the rapidity of patient care (Bracken, 2003). In the 1960s, as emergency department censuses began to grow, the need for triage was recognized. Initially triage was performed by a physician or nurse physician team. Today, triage is generally performed by experienced emergency department nurses (Gilboy, Travers, & Wuerz, 1999). Triage is performed in both the prehospital and hospital environments. Triage is a fluid process and is based on the number of patients, the amount of resources available, and the care that is available. Triage is an important component of emergency nursing practice as patient censuses continue to increase and more has to be provided with less.

IOM Report and the Future of Emergency Care

In June 2006, the Institute of Medicine released a report on the state of emergency care in the United States. The IOM report

CULTURAL CONSIDERATIONS for Emergency Care Providers

The cultural competence of emergency care providers should include an awareness of existing racial and ethnic health disparities and recognition of the incidence and prevalence of health problems among diverse populations that may present to the emergency department for care. A culturally competent emergency care provider also possesses the skills to identify and manage racial and ethnic differences in health values, beliefs, and behaviors, incorporating these so that patients receive the best care in the emergency department (Cone, Richardson, Todd, Betancourt, & Lowe, 2003; Lipson & Dibble, 2007).

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NATIONAL GUIDELINES Summary of IOM Recommendations for Emergency Care in the United States Recommendation
Improve hospital efficiency and patient flow through the emergency department.

Actions
Use tools from other disciplines such as engineering and operations research to improve patient flow. Establish clinical decision units or 24-hour observation units to hopefully prevent unnecessary admissions. Increase use of informational technologies to track and coordinate patient flow. Develop standards through accreditation bodies for crowding, boarding, and diversion. Develop regionalized systems that include hospitals, emergency medical services (EMS), and other agencies working together. Patients should be taken to the care center that can provide the optimal care, for example, to trauma or stroke centers. Develop well-defined standards and performance improvement measures. Fund research to identify best practices. Request reimbursement for care of all patients who are treated in the emergency department. Acquire funding for disaster preparedness. Develop triage and transport protocols designed to provide children with the most appropriate care. Educate and train emergency care providers to care for children. Include pediatric concerns as part of disaster plans. Hire pediatric coordinators in EDs and EMS agencies to ensure that appropriate equipment, training, and services are provided to children.

Create a coordinated, regionalized, accountable emergency care system.

Increase funding for emergency care systems.

Improving pediatric emergency care.

Source: Institute of Medicine. (2006). Hospital-based emergency care at the breaking point. Washington, DC: National Academy of Sciences.

CHART 732 CHART 731

Role Urgent care center nursing Prehospital nursing

Specialty Roles in Emergency Nursing

Description This is a nurse who is responsible for the educational needs of the emergency department. This role may also include patient and community education. ENPs are nurse practitioners who specialize in providing advanced nursing practice. There is no specific certification for emergency nursing, however, many ENPs hold certifications as family nurse practitioners, acute care nurse practitioners, pediatric nurse practitioners, or adult nurse practitioners. A clinical nurse specialist is prepared at either the masters or doctoral level as an expert in emergency nursing. An ECNS may provide direct patient care, provide education, develop and perform research, and serve as a role model and change agent in the emergency department. An emergency case manager can provide care to a single patient or a group of patients. Case managers interact with many departments and outside agencies to assist the patient, families, and emergency department staff with care issues such as home health, drug dependence, and psychiatric problems so that the best and most cost-effective care is given to the patient.

Emergency Nursing Roles

Description Nurses provide care in free-standing facilities that provide urgent care for minor illnesses and injuries. Nurses provide care in the prehospital care environment. These nurses are prepared through additional education that is generally regulated by the states in which they practice. For example, some states require nurses to take a prehospital nursing course or become emergency medical technicians (EMTs) or EMT-paramedics. Nurses accompany air or ground transport patients. Even though many nurses who perform transport may have emergency nursing experience, transport nurses may also have critical care nursing experience. Nurses provide care as part of their military service. Nurses provide care to specific industries or companies. Basic life support and ACLS are additional responsibilities of many of these nurses. Nurses provide care in prisons and jails.

Role Nurse educator

Emergency nurse practitioner (ENP)

Transport nursing

Emergency clinical nurse specialist (ECNS)

Case manager

Military nurses Industrial nursing and occupational health nursing Correctional nursing

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Disaster, Emergency, and Trauma Nursing patients chief complaint or reason why she came to the emergency department. Charts 734, 735, and 736 contain mnemonics that can assist with collecting historical data in triage. Even though the CIAMPEDS mnemonic is directed more at collecting data for a pediatric patient, it can easily be adapted for the adult patient as well (ENA, 2004). A brief, but focused physical assessment should be performed. Objective data can be collected by using a primary assessment that includes airway, breathing, circulation, and disability. The components of the primary assessment are discussed in detail in Chapter 74 . A secondary assessment may be required in some cases to better differentiate the severity of a patients condition. The secondary assessment should include exposure with environmental control, a full set of vital signs and family presence, provision of comfort, additional history, and a head-to-toe assessment as needed using inspection, palpation, and auscultation. The components of the secondary survey are discussed in detail in the Chapter 74 .

The goals of triage include: Early and brief patient assessment Determination of the patients urgency for care Documentation of findings Control of patient flow through the emergency department Assignment of patients to the appropriate care area Initiation of diagnostic measures Initiation of limited therapeutic interventions Infection control Promotion of public relations Health education for patients and families

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An important part of triage is the intuitiveness that the emergency nurse may have about the patient. The triage nurse recognizes that there is something wrong. Oftentimes, few data are available to validate these feelings. However, experienced emergency department nurses are good resources to alert new nurses about how to identify the less obvious indicators that a patient may be in trouble.

CHART 734

CIAMPEDS Mnemonic

Types of Triage
The type of triage that is used in an emergency department is dependent on several things including patient census, department layout, and number and type of staff. As previously stated, triage is usually performed by an experienced registered nurse. However, other types of triage models are summarized in Chart 733.
C I I A M P E D D S Chief complaint Immunizations Isolation: exposed to a disease or hazardous material that may put the rest of the department in danger Allergies Medications Parents or caregivers impression about the patient Events surrounding the illness or injury Diet Diapers or output Symptoms associated with the chief complaint, for example, fever, nausea and vomiting

Components of Triage
Triage begins with an across the room assessment. This involves what the triage nurse sees, smells, or sometimes even feels when first evaluating the patient. For example: Is the patients airway open or is he drooling? Is the patient breathing and, if so, is the breathing effective? What is the patients skin color: normal, pale, flushed? Are there any obvious signs of illness or injury?

A minimal amount of information should be gathered about why the patient has presented to the emergency department. Several mnemonics can be used to gather data depending on the CHART 733
Type of Triage Traffic director Spot check

CHART 735
M V I T

MVIT Mnemonic

Mechanism of injury Vital signs Injury Treatment

Types of Triage
Components

Nonprofessional (hospital registrar) Writes down chief complaint. Nurse/physician Evaluates patient. Assigns an urgency category. Registered nurse Evaluates patient. Assigns an urgency category. Implements interventions (e.g., ordering a radiograph). Administers pain medication.
A M P L E

CHART 736
Allergies

AMPLE History Mnemonic

Comprehensive triage

Medications Past medical history Last meal Everything that is related to the chief complaint

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Gerontological Considerations
With the aging population, it is important for the emergency department (ED) nurse to be familiar with the unique aspects of elderly assessment and planning of care. At a hospital in Canada that received 51,000 ED visits annually, adults who were 70 years of age or older used approximately 70% of the total bed days, and in 2005, those 75 years of age and older had an ED admit rate of approximately 37%, compared to an average admit rate for all ages of 15% (Sendecki, 2007). For this reason the hospital in Canada developed a course that applied geriatric/geropsychiatric knowledge, skills, and abilities the ED nurse can implement into their daily practice. An example is the need to assess falls as a symptom that requires investigation of root causes, treatment plan follow-up, and risk reduction to prevent another fall. They also assigned a position in the ED for a geriatric emergency nurse (GEN). The focus of the GEN is to identify needs and start a proactive care plan that is used during the patients admission. The GEN also alerts community care to anticipated needs upon discharge. At the end of a 4-month trial they found that the GEN had seen approximately 25% of all patients who were 75 years of age or older; of those, 50% were admitted to the hospital; and the average length of stay of those who had been assessed by the GEN was 11.5 days, compared with 15.4 for those of the same age group not seen by the GEN (Sendecki, 2007). The ENA has also focused on ED care for elderly patients, as outlined in the Gerontological Considerations box. Chapter 10 provides detailed information regarding the aging patient.

Many emergency departments use a three-level urgency category, but the continued increase in emergency department censuses, the augmented acuity of patients who are being cared for in the emergency department, and the numbers of patients who use the emergency department for primary care have prompted the use of additional levels of urgency. Charts 737 and 738, respectively, summarize four- and five-level triage urgency scales. There are resources available such as the Emergency Severity Index from the Emergency Nurses Association that describes the use of a five-level triage urgency category.
Even when patients have been assigned a triage category, their condition may change, so patients who must wait for care must be reassessed at specific intervals. Triage policies and procedures should reflect when this must be done and documented. Unfortunately, patients have suffered significant harm and even death while waiting to be seen!

Disaster Triage
When a disaster occurs (earthquake, tornado, terrorist event), triage is directed at rapidly identifying patient urgency, assigning a category, and rapidly deploying to the most appropriate area for care. However, in a disaster, there may not be enough personnel or resources to care for everyone. In such a case, care may be withheld so that limited resources are used for those who will survive (Delaney & Drummond, 2002). During a disaster, many emergency departments and community disaster programs use the START (simple triage and rapid treatment) system. This system evaluates respirations, perfusion, and mental status in order to determine who needs immediate transport, who can wait, or who may be unsalvageable. Color codes are used as a method of identification and communication. For example, green may mean that the patient can walk to an area for care (Super, Groth, & Hook, 1994). Refer to Chapter 72 for a detailed description of the START triage system. Each emergency department and community should have a disaster plan that describes the manner of triage that should be employed during a disaster. The roles of the emergency nurse and other staff members should be practiced on a regularly

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Triage Urgency Categories

Once an initial evaluation has been made related to the patients physical condition and chief complaint, the triage nurse will assign the patient an urgency category. Urgency categories rate patient acuity and assist in prioritizing care. Generally, an emergent patient is one who has an immediate life-threatening problem, for example, an airway obstruction. An urgent patient can wait a little longer, but would need to be seen as soon as possible. An example is a patient with chest pain, cardiac risk factors, and stable vital signs. Finally, a nonurgent patient can wait for care.

CHART 737

Four-Level Triage
Resuscitation Emergent Urgent Nonurgent

GERONTOLOGICAL CONSIDERATIONS in the Emergency Department

The Emergency Nurses Association has developed an online course entitled Geriatric Emergency Nursing Education (GENE). The course covers best practices that can be used to deliver optimal care and respond to the special needs of older adults. The course covers these topics: Attitudes and ageism Physical and psychological changes Atypical presentation of illness Triage Pain management Abuse and neglect Palliative care Discharge planning

Level I Level II Level III Level IV

CHART 738
Level I Level II Level III Level IV Level V

Five-Level Triage
Resuscitation Emergent Urgent Semiurgent Nonurgent

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Disaster, Emergency, and Trauma Nursing The emergency nurse will generally encounter three types of consent. These include a general (blanket) consent, which is usually obtained at registration. This type of consent form will allow for evaluation and treatment, such as radiographs, laboratory tests, and medications. If more invasive tests are needed or the patient must undergo a specific procedure such as a fracture reduction that requires conscious sedation, informed consent should be obtained. Informed consent involves the patient stating by signing that he has a full understanding of the procedure, including its risks, and is competent to give consent. Even though the emergency nurse should check to see that a consent form has been signed, it is the physicians responsibility to obtain informed consent. Finally, implied consent allows treatment in an emergency situation based on the presumption that if the patient were able to, she would give permission for treatment (Lee, 2003). Each state dictates ages of consent, situations that may allow for legal consent despite age (pregnant underaged females), and other interesting nuances related to consent. It is imperative that the emergency nurse be familiar with the applicable state laws and hospital policies related to consent.When in doubt, always safely err on the side of the patient and when possible consult hospital risk management personnel before acting. It is also important to document why decisions were made to prevent any legal second-guessing.

scheduled basis. Additional information about disaster management is provided in Chapter 72 .

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Legal Issues
The practice of emergency nursing requires comprehension and understanding of some of the legal issues that impact the emergency department. Three of these issues are discussed here: the Emergency Medical Treatment and Active Labor Act, consent, and evidence collection.

Emergency Medical Treatment and Active Labor Act

The Emergency Medical Treatment and Active Labor Act (EMTALA) is a part of the 1986 COBRA laws and the 1990 OBRA amendment that defines the legal responsibilities of Medicare-participating hospitals in treating individuals who present with emergency medical conditions (Federal Register, 2003). In summary, EMTALA provides that: A hospital is required to perform a medical screening exam to determine if there is an emergency when a patient presents to the emergency department. If it is determined that an emergency condition exists, the hospital must provide for further medical examination and treatment as required to stabilize the patient. If the hospital does not have the capabilities to provide the care needed, the patient may be transferred. An appropriate transfer is one in which the medical benefits outweigh the risk of transport or the patient makes an informed consent for transfer. The patient must be transferred with an appropriate level of care provided during the transport process. A hospital may never delay an appropriate medical screening examination or further examination or treatment to inquire about the patients payment method or insurance status. Also under EMTALA, hospitals that receive patients who may have been inappropriately transferred need to report this; signs must be posted in the emergency department that explain a persons rights to emergency treatment (most emergency departments have these posted in multiple languages); and hospitals must maintain patients records, a physicians on-call list, and emergency department logs. Failure to adhere to these regulations can result in both institutional and individual fines and loss of federal funding. In summary, EMTALA provides that all patients who seek treatment in the emergency department have a medical screening and treatment as deemed appropriate based on their emergency. No patient can be turned away for financial reasons.

Evidence Collection and Preservation

Unfortunately, a major part of emergency nursing practice is caring for the victims of violence. Sexual assault, domestic assault, and motor vehicle crashes are only a few of the examples of the types of patients who may require that the emergency nurse collect and preserve evidence. Forensic evidence is something that is legally submitted to a court of law as a means of determining the truth related to an alleged crime (Doyle, 2001). Examples of evidence include clothing, body fluids, bite marks, and photographs of injuries.
Every emergency department should have a policy and procedure for the collection and preservation of evidence. Improper collection and preservation could lead to erroneous interpretation of the evidence.

Evidence must be collected using a specific protocol and procedure that includes how to label the evidence, preserve it, and maintain the chain of custody. Some evidence collection protocols are directed by specific legal agencies or even state agencies. Chart 739 contains a summary of procedural steps for evidence collection and preservation in the emergency department (Semonin-Holleran, 2004).

Preparation for Practice

Preparation for practice in the emergency department for new graduates or nurses without emergency experience can be demanding. Nursing care in the emergency department includes learning to manage the care of four or five patients simultaneously; starting all of the patient care, for example, inserting intravenous lines and drawing blood for evaluation; limited and focused patient assessment, oftentimes with little or no patient information; discharge teaching and planning; and care of populations and patient problems not frequently encountered in admitted patients such as acute psychosis, sexual assault, and

Consent
Consent is defined as giving permission to do something. However, the nature of emergency practice does not always allow the patient or family the ability to consent to all of the treatments that may be needed to save a life. Most states recognize this problem in the emergency department and have allowed consent to be waived when there is a life- or limb-threatening emergency (Lee, 2003).

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CHART 739

Collection and Preservation of Evidence and Chain of Custody

10. Evidence should be sealed with evidence tape. Never lick evidence envelopes. 11. Photographs may be taken by an emergency nurse. They must be labeled and stored in a secured area. Only take photographs if experienced in how to do it properly. 12. Document the evidence collection procedure. Use checklists when available. 13. Place evidence in a secure, locked area until it is released to the appropriate authorities. 14. Maintain the chain of custody, who collected the evidence, anyone who touches or secures it and what is done with the evidence until it is given to law enforcement, for all evidence. 15. Complete the chart and document what was given to authorities and who received the evidence.

1. Identify the indications for evidence collection and consult authorities to ensure that the appropriate evidence is collected and preserved. 2. Obtain and use the appropriate evidence collection kit. 3. Obtain patient consent according to hospital policy and procedure. In some cases consent may not be necessary, for example, in a homicide investigation. Consult appropriate authorities. 4. When collecting evidence, change gloves frequently to prevent cross contamination. 5. Try not to perform any wound care until photographs have been taken. 6. Place evidence in individual labeled containers. 7. Wet evidence should always be dried before packaging. 8. Always place evidence in a paper bag. 9. Label all evidence with this information: a. Patients name b. Source of collection c. Date d. Time e. Person collecting the evidence.

homelessness. It also requires familiarity with diverse patient populations, varied age groups, and social problems that may never be solved (Proehl, 2002). Additional education for new orientees to the emergency department should include: Advanced Cardiac Life Support (ACLS) Trauma Nursing Core Course (TNCC) Emergency Nursing Pediatric Course (ENPC). Nursing care for patients or conditions not frequently encountered by new orientees with their limited experience (e.g., obstetrics and gynecology; eye, ear, nose, and throat; pediatric and psychiatric emergencies) should also be included.

Discharge instructions should include information about follow-up care. In some emergency departments, patients may be asked to return; in other EDs, patients may be referred to a physician, advanced practitioner, or clinic. It is important to ensure that the patient or family members understand the information that is provided. Asking the patient questions or to do a return demonstration may assist in determining the level of understanding. Some emergency departments have instituted follow-up calls to not only find out about follow-up care, but to check on the patients status. It is important to allow the patient or family the opportunity to ask questions and feel as comfortable as possible with the prescribed care for their illness or injury

Discharge Priorities
The majority of patients seen in the emergency department are sent home rather than admitted to the hospital.An important part of discharge planning is providing information about how to manage the problem that brought the patient to the emergency department and where the patient should obtain further care. Discharge instructions should be clear and use terminology that the patient understands. Most educators recommend that discharge instructions be written at a fifth- or sixth-grade level. When possible, they should be translated into a language that the patient or family understands or at a minimum an interpreter should be present when the instructions are given. Illustrations of what is expected (e.g., how to wrap an elastic bandage on an injured extremity) may be of assistance. Instructions must also be age appropriate. This is especially important when medications are being prescribed. Many commercial programs that provide discharge instructions are available. These instructions can be printed and sent with the patient or, in some cases, they can be accessed online from the patients home.

Health Promotion
Emergency nurses not only play a key role in the management of ill or injured patients, but also in injury and disease prevention. One primary example is through Emergency Nurses CARE (ENCARE). ENCARE was started by two emergency nurses in the 1980s who had become involved in trying to prevent injuries and death from alcohol-related emergencies (ENA Injury Prevention Institute/ENCARE, 2008). Emergency Nurses CARE has now become the Injury Prevention Institute/ENCARE of the Emergency Nurses Association. ENCARE provides training for volunteer nurses and emergency medical technicians related to specific issues such as injury prevention and public health issues. Currently ENCARE provides five primary education and prevention programs: Alcohol Awareness Program Bike and Helmet Safety Child Passenger Safety Gun Safety: Its No Accident Healthy Aging: Take Care.

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Through the efforts of its many volunteers, ENCARE has reached hundreds of thousands of people throughout the United States. Much research has been done and is ongoing regarding injury prevention and the best ways to educate communities. Other research opportunities for emergency nursing are included in the Research Opportunities and Clinical Impact feature.

ETHICAL ISSUES Regarding Pain Management in the Emergency Department

Pain is the most common complaint seen in the emergency department. Despite this, only 40% to 60% of the patients are treated for pain. Many patients face oligoanalgesia, in which no interventions are provided for pain relief despite patient complaints of pain when they come to the emergency department. Many reasons are cited for this, including fear of masking symptoms and concern about the physiological effects of pain medications. Other studies have demonstrated that women and minorities do not receive appropriate pain management. Emergency nurses need to be patient advocates and ensure that a patients pain is assessed, documented, and managed. Pain management requires a collaborative approach including protocols so that analgesic agents can be administered as soon as possible. All patients should receive pain care (Knox et al., 2007).

Summary
The practice of emergency nursing involves the care of diverse patient populations in many types of situations. It requires skills that include the ability to identify critically ill and injured patients and start their care from the beginning and patience with difficult societal problems such as caring for the homeless. It also involves ethical challenges as described in the Ethical Issues feature, and the practice of emergency nursing should be evidenced based. The Evidence-based practice feature gives an example of evidence-based nursing practice in the emergency department. Emergency nursing encompasses all aspects of care from pediatric to geriatric, medical to surgical, and to a very diverse popu-

lation of patients both culturally and economically. It requires excellent assessment and critical thinking skills as well as procedural proficiency. Emergency nursing is a rewarding way to nurse.

Family Presence during Resuscitation in the Emergency Department Clinical Problem

Should the family be allowed to be present during resuscitation in the emergency department? allowed; all staff need to be prepared and trained; well-qualified and trained staff should always accompany the patient; and resources must be available to the staff to help them cope with any issues that may arise (Walker, 2006).

Research Findings
In 1982, the Foote Hospital in Michigan surveyed 13 surviving relatives about whether they would have liked to be present during the resuscitation of their family members. Seventy-two percent said that they would have liked to have been present. A program was developed to allow selected accompanied family members to be allowed to be present during resuscitation. Seventy family members and 21 physicians, nurses, and others were surveyed after the event. Seventy-six percent of the family members felt that being present assisted them in their grieving process. They also felt that the patient did not die alone and emergency care providers did everything that they could. Staff members, however, felt hampered in their resuscitation efforts and reported increased stress because the patients became more human in the presence of family members. No family member interfered with the resuscitation efforts (Doyle et al., 1987). This landmark study opened the floodgates to consider the role of the family in resuscitation. Since 1987, more than 60 papers have been published that address this issue. Families have expressed that they are not concerned about what they may see or hear in the resuscitation areathey just want to be with their family member. More than half of the families felt they had a right to be present and, again, felt that their grieving process was aided. The staffs perspective includes fear of interference from the family and the need to display more professional behaviors during the resuscitation process. Interestingly, physicians are more opposed to family presence than are nurses.

Critical Thinking Questions

1. What should be in place in the emergency department to allow family presence? a. A clergy member to provide spiritual care for the patient and family b. A policy and procedure that describes how to implement the process c. Staff who object to the presence of a family member during resuscitation d. Security or police so that the family is kept away during resuscitation 2. Which of the following fears have staff members expressed when allowing a family member to be with a patient during resuscitation? a. Fear that the family member may interfere with the resuscitation b. Fear that they must see the patient as a human being during the resuscitation c. Fear that they must act more professionally during the resuscitation d. All of the above

References
Doyle, C., Post, H., Burney, R., Maino, J., Keefe, M., et al. (1987). Family participation during resuscitation: An option. Annals of Emergency Medicine, 16, 673675. Walker, W. (2006). Witnessed resuscitation: A concept analysis. International Journal of Nursing Studies, 43, 377387. Answers to Critical Thinking Questions appear in Appendix F.

Implications for Nursing Practice

When implementing family presence in the ED during resuscitation, a policy needs to be in place that addresses when it can and cannot be

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RESEARCH OPPORTUNITIES AND CLINICAL IMPACT RELATED TO EMERGENCY NURSING Research Area
Physiological Research The management of acute and chronic pain in the emergency department Use of alternative methods to manage pain in the emergency department

Clinical Impact
Many patients do not have their pain appropriately managed and frequently present to the emergency department for pain medication. Alternative methods of pain management such as acupuncture, acupressure, and massage could be used by nurses to manage pain in the emergency department. Innovative assessment and monitoring methods and treatment therapies would emerge for the management of the patient in shock. Identify how to include the family in the care of their critically ill or injured family member. Assist in end-of-life decision making. Learn to manage the limited resources of emergency departments, including nursing staff, in order to meet the needs of all patients, particularly the uninsured and underinsured patients who use the emergency department for their health care. Decrease return visits and get patients into the appropriate health care systems, thereby decreasing costs.

Development of guidelines to manage shock in the emergency department Psychosocial, Ethical, and Legal Research Effectiveness of family presence during invasive procedures and resuscitation Problem of overcrowding in emergency departments and ambulance diversion by EDs.

Effectiveness of follow-up phone calls within 24 hours of a patient visit.

NCLEX REVIEW
1. As it relates to the practice of emergency nursing, the nurse understands that:
1. It always involves episodic client care that is usually chronic or critical in nature. 2. It can describe client care for perceived, actual or undiagnosed health problems. 3. It has long been associated with Judith Kelleher and her care of wounded soldiers. 4. It is challenged to become culturally competent as the clients become analogous. 1. 2. 3. 4. Level I Resuscitative. Level II Emergent. Level III Urgent. Level IV Non-urgent.

2. You are the emergency department nurse responsible for triage. All of the following patients present simultaneously for care. With your triage assessment complete, which patient should be treated first?
1. A patient complaining of chest pain and shortness of breath with pale, clammy skin, nausea and diaphoresis. 2. A patient with a three centimeter laceration to the right forearm with normal sensation and minimal bleeding. 3. A patient having a possible allergic reaction with facial edema, drooling, stridor and severe urticaria with pruritis. 4. A patient experiencing increasingly more severe problems urinating and has a large palpable bladder.

4. The patient presents to the Emergency Department with a left shoulder dislocation that must be reduced quickly as the radial pulse on the affected side is no longer palpable. The injury occurred 30 minutes prior to arrival, and the client states they are experiencing severe pain. The emergency nurse understands that which of the following consents must be obtained prior to this patients treatment?
1. 2. 3. 4. General consent and informed consent. Informed consent and implied consent. Implied consent and blood product consent. Blood product consent and general consent.

5. You are orienting a new nurse graduate to the Emergency Department. Which of the following statements made by the new nurse regarding preparation for emergency nursing would indicate the need for further instruction?
1. I am planning on taking additional training to help prepare myself to deal with any potential psychiatric emergencies. 2. I am glad that emergency nurses do not have to deal with obstetrical issues because they can call the labor and delivery nurses. 3. I will take the Trauma Nursing Core Course soon because I know I need more experience with trauma assessment. 4. I now feel more confident in my time management skills when it comes to caring for multiple clients simultaneously.
Answers for review questions appear in Appendix F

3. The patient presents to the Emergency Department with a complaint of non-traumatic back pain for four months that has previously been evaluated by their primary care provider. The patient states, I ran out of my pain medicine last night, and my doctor refuses to call in another prescription. Objective findings are unremarkable. Vital signs are HR 89, BP 130/60, RR 18, T 98.9F, SpO2 99% and pain 5 on a 0-10 scale. Based on the four-level system, how should this patient be categorized at triage?

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UNIT 16

Disaster, Emergency, and Trauma Nursing

KEY TERMS
emergency nursing p.000 Emergency Medical Treatment and Active Labor Act (EMTALA) p.000 forensic evidence p.000 oligoanalgesia p.000 triage p.000

EXPLORE
MyNursingKit is your one stop for online chapter review materials and resources. Prepare for success with additional NCLEX-style practice questions, interactive assignments and activities, web links, animations and videos, and more! Register your access code from the front of your book at www.mynursingkit.com

REFERENCES
Bonalumi, N., & King, D. (2007). Professionalism and leadership. In S. Hoyt and J. Selfridge-Thomas (Eds.), Emergency nursing core curriculum (6th ed.). Philadelphia: W. B. Saunders. Bracken, J. (2003). Triage. In L. Newberry (Ed.), Sheehys emergency nursing: Principles and practice (5th ed.). St. Louis: Mosby. Cone, D. C., Richardson, L. D., Todd, K., Betancourt, J., & Lowe, R. (2003). Health care disparities in emergency medicine. Academic Emergency Medicine, 10(11), 11761183. Delaney, J., & Drummond, R. (2002). Mass casualties and triage at a sporting event. British Journal of Sports Medicine, 36, 8588. Doyle, C., Post, H., Burney, R., Maino, J., Keefe, M., et al. (1987). Family participation during resuscitation: An option. Annals of Emergency Medicine, 16, 673675. Doyle, J. S. (2001). Evidence collection handbook from the Kentucky State Police. Retrieved October 10, 2008, from http://firearmsid.com/ KSP%20Evidence%20Manual/KSP%20Manual%20Main.htm Emergency Nurses Association. (1999). Emergency Nurses Association scope of emergency nursing practice. Des Plaines, IL: Author. Emergency Nurses Association. (2004). Emergency nursing pediatric course. Des Plaines, IL: Author. ENA Injury Prevention Institute/ENCARE. (2008). History and background. Retrieved October 10, 2008, from http://www.ena.org/ipinstitute/ history

Federal Register. (2003). Department of Health and Human Services 42 CFR Parts 413,482, and 489 Medicare programs; Clarifying policies related to the responsibilities of Medicare-participating hospitals in treating individuals with emergency medical conditions. Final rule September 9, 2003. Gilboy, N., Travers, D., & Wuerz, R. (1999). Re-evaluating triage in the new millennium: A comprehensive look at the need for standardization and quality. Journal of Emergency Nursing, 25(6), 463473. Institute of Medicine. (2006). Hospital-based emergency care at the breaking point. Washington, DC: National Academy of Sciences. Knox, T., Ducharme, J., Choiniere, M., Crandall, C., Fosnocht, D., Homel, P., et al. (2007). Pain in the emergency department: Results of the Pain and Emergency Department Initiative (PEMI) multicenter study. Journal of Pain, 8(6), 460466. Lee, G. (2003). Legal and regulatory constructs. In L. Newberry (Ed.), Sheehys emergency nursing: Principles and practice (5th ed.). St. Louis: Mosby. Lipson, J. G., & Dibble, S. L. (Eds.). (2007). Culture and clinical care. San Francisco: UCSF Nursing Press. MacPhail, E. (2003). Overview of emergency nursing. In L. Newberry (Ed.), Sheehys emergency nursing: Principles and practice (5th ed., pp. 15). St. Louis: Mosby.

National Center for Health Statistics. (2007). Emergency department visits. Retrieved September 10, 2007, from http://www.cdc.gov/ nchs/fastats/ervisits.htm Proehl, J. (2002). Developing emergency nursing competence. Nursing Clinics of North America, 37(1), 8996. Reeder, T. J., & Garrison, H. G. (2001). When the safety net is unsafe: Real-time assessment of the overcrowded emergency department. Academic Emergency Medicine, 8(11), 10701073. Schriver, J., Talmadge, R., Chuong, R., & Hedges, J. (2003). Emergency nursing. Journal of Emergency Nursing, 29(5), 431439. Semonin-Holleran, R. (2004). Preservation of evidence. In J. Proehl (Ed.), Emergency nursing procedures. Philadelphia: W. B. Saunders. Sendecki, C. (2007). Care of the acutely ill elderly in ER: Growth of the role of geriatric ER nurses. Outlook (Fall 2007). Super, G., Groth, S., & Hook, R. (1994). START: Simple triage and rapid treatment plan. Newport Beach, CA: Hoag Memorial Hospital. Thomas, D. O., Bernardo, L. M., & Herman, B. (2003). Core curriculum for pediatric emergency nursing. Boston: Jones and Bartlett Publishers. Walker, W. (2006). Witnessed resuscitation: A concept analysis. International Journal of Nursing Studies, 43, 377387.