DEFINITION EMERGENCY NURSING According to the ENA, the definition of Emergency nursing involves the assessment, diagnosis, and

treatment of perceived, actual or potential, sudden or urgent, physical or psychosocial problems that are primarily episodic or acute. These may require minimal care or lifesupport measures, education of client and significant others, appropriate referral and knowledge of legal implications.

HISTORY OF EMERGENCY NURSING Emergency nursing was officially recognized as a specialty in 1970. The national association representing these nurses LS the Emergency Nurses Association (ENAI. Its current membership comprises more than 25,000 nurses who have chosen this area of professional nursing. The ENA is recognized internationally and by 1999 had approximately 400 members from 35 different countries. Emergency nurses throughout the world have realized both their similarities and differences through use of the World Wide Web and increasing international globalization. The ED of the future is being formulated today. Not only is technology changing, but the day-to-day processes that support the ED infrastructure are being challenged and redesigned. These include concepts such as incorporating multiple triage stations and bedside or back-end client registration; using computerized protocols, guidelines, and electronic medical records; integrating nontraditional health care modalities; initiating wireless communication technology; and creating virtual EDs. In addition to the provision of direct client care, other multifaceted roles exist within emergency nursing. The emergency nurse is involved in the initial triaging of clients according to illness severity, may perform as a mobile intensive care nurse (MICN) by directing pre-hospital care personnel via telecommunication, and frequently provides client care in the pre-hospital environment. Community clinics use ED nurses, and many emergency nurses have become active in injury prevention programs at both national and local levels. Advanced practice roles such as clinical nurse specialists and nurse practitioners are integrated into many EDs throughout the United States. Nurses in these advanced practice roles often have a masters degree level of education or higher in addition to specialty certification.

SCOPE OF EMERGENCY NURSING The emergency nurse has had specialized education, training, and experience to gain expertise in assessing and identifying patients health care problems in crisis situations. In addition, the emergency nurse establishes priorities, monitors and continuously assesses acutely ill and injured patients, supports and attends to families, supervises

allied health personnel, and teaches patients and families within a time-limited, highpressured care environment. Nursing interventions are accomplished interdependently, in consultation with or under the direction of a licensed physician or nurse practitioner. The strengths of nursing and medicine are complementary in an emergency situation. Appropriate nursing and medical interventions are anticipated based on assessment data. The emergency health care staff members work as a team in performing the highly technical, hands-on skills required to care for patients in an emergency situation. The nursing process provides a logical framework for problem solving in this environment. Patients in the ED have a wide variety of actual or potential problems, and their condition may change constantly. Therefore, nursing assessment must be continuous, and nursing diagnoses change with the patients condition. Although a patient may have several diagnoses at a given time, the focus is on the most lifethreatening ones; often, both independent and interdependent nursing interventions are required.

LEGAL AND ETHICAL ISSUES IN EMERGENCY NURSING A. LEGAL ISSUES 1. FEDERAL ISSUE a. Past federal legislation has mandated that any client who presents to an ED seeking treatment must be rendered aid regardless of financial ability to pay for services. Since the mid-1980s, additional specific legislation has been enacted requiring ED personnel to stabilize the condemn of any client considered medically unstable before transfer to another health care facility the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 -and the Omnibus Budget Reconciliation Act (OBRA) of 1990. This stabilization mtist occur regardless of the clients financial ability to pay for services. ED personnel who transfer clients to another institution without first providing this initial stabilization can incur substantial fines and penalties, as can the hospital administration. b. Clients have continued to seek health care services in the ED, even with the proliferation of managed health care plans and gatekeeping policies. The financial integrity of the ED has been challenged over the years due to the legal obligations of the ED to provide service. c. Retrospectively, financial reimbursement for rendered services has been denied to EDs from managed health care plans following a determination that the clients problem did not constitute a true emergency d. Additional legislation was enacted (Emergency Medical Treatment and Active Labor Act EMTALA in 1988, 1989, 1990, and 1994) requiring that a medical screening examination be performed on all ED clients before solicitation of information about ability to pay.3 This medical screening examination must

be inclusive enough to determine whether the client is experiencing an emergency medical condition requiring treatment or, in the case of a pregnant woman, is experiencing labor contractions. An emergency medical condition includes drug abuse, hemodynamic instability, psychiatric illness, intoxication, severe pan, and labor. e. If a client has an emergency medical condition, stabilization must be rendered. Stabilization is interpreted to mean that deterioration of the client is unlikely during possible transfer or discharge of the client. Continued interpretations of this act have expanded the facilities that come under EMTALA. These include not only EDs. but also hospital owned urgent care centers, anywhere unscheduled clients appear for medical care, and off site locations that are within a 250-yard zone of a main hospital that is covered under the 2001 outpatient prospective payment system. Violations of this legislation can again result in fines and penalties. 2. CONSENT TO TREAT a. Most adult clients seeking treatment in the ED give voluntary consent to the standard and usual treatment performed in this setting. In some instances, however, a client is deemed unable to give consent for treatment. This inability may be due to the critical nature of the clients illness or injury or to other conditions, such as an altered level of consciousness. In these instances, emergency care may be rendered to the client under the implied emergency doctrine. This doctrine assumes that the client would consent to treatment to prevent death or disability if the client were so able. b. Children younger than the age of legal majority must have the consent of their parent or legal guardian for medical care to be rendered. Exceptions include (1) emancipated minors, (2) minors seeking treatment for communicable diseases, including sexually transmitted diseases, injuries from abuse, and alcohol or drug rehabilitation, and (3) minor-aged females requesting treatment for pregnancy or pregnancy-related concerns. Some states also allow the adult caregiver with whom the child resides to give treatment authorization even though that caregiver may not be the parent. c. The issue of informed consent in the ED is the same as in any other health care setting. Adult clients must he informed about the necessity of required treatments, expected outcomes, and potential complications. Clients must also be mentally competent and understand the information being explained. As in any other setting, a mentally competent adult client always maintains the right to refuse treatment or withdraw previously given consent. 3. RESTRAINTS a. Restraining a client while he or she is in the ED may at times be necessary. The need for restraints usually arises because the client is becoming agitated or potentially violent. Hard leather or chemical restraints are used in the ED if

b. c.

d. e.

f.

g. h.

i.

the client is in danger of injuring self or others and when nonphysical methods of controlling the client are not viable. Restraints may not he used to control a client solely for convenience or because of staffing issues. When restraints are required, departmental and hospital guidelines that are in compliance with Joint Commission and the Centers for Medicare & Medicaid Services must he followed. A physicians order for applying restraint as well as the clients behavior mandating the use of restraints most be documented. The client must be periodically reevaluated both for the continued need or restraints and the integrity of distal circulation, motor movement, and sensory level of the restrained extremities. The findings must be documented. Offering water to the client and providing opportunities to urinate or relieve other body needs are required, as is documentation of this nursing care. No client may be kept restraints against his or her will unless the clients behavior indicates the existence of safety issues. Behavior modification techniques used in an attempt to release the client from restraints must also be documented. The ED staff must receive appropriate education pertaining to dealing with clients requiring physical restraint. Clients in the ED who have psychological conditions that render them a danger to themselves or to others, or who are unable to provide food or shelter for themselves, can be placed and held on a legal psychiatric restraining order. THIs order mandates that such clients be placed in a locked psychiatric facility for their protection for a maximum of 72 hours. Within that 72-hour period, the client must be evaluated by a psychiatrist to determine whether the legal hold needs to be extended or whether the client can be released.

4. MANDATORY REPORTING a. Every state has mandatory reporting regulations that affect emergency nurses. Incidents and conditions may need to be reported to federal, state, or local authorities or to the Department of Public Health, Department of Motor Vehicles, coroners offices, or animal control agencies. b. The types of incidents requiring reporting are suspected child, sexual, domestic, and elder abuse; assaults; motor vehicle crashes; communicable diseases such as hepatitis, sexually transmitted diseases, chicken pox, measles, mumps, meningitis, tuberculosis, and food poisoning; first time or recurrent seizure activity; death; and animal bites. c. Every ED has written policies regarding these mandatory reports. 5. EVIDENCE COLLECTION AND PRESERVATION

a. Recognition of unusual circumstances surrounding a clients injury or death is an important aspect of ED nursing because of the associated legal implications. Not only must tile legal authorities be notified, but also, in many instances, the ED nurse may be required to collect and preserve evidence taken from the client. This evidence can include bullets, weapons, clothing, and body fluid specimens. b. All collected evidence must be identified by the clients name, hospital identification number, date and time of evidence collection, type of evidence and source e.g. venipuncture, hematoma, aspiration vomitus, swab), and the initials or signature of the person collecting the evidence. Once the evidence has been collected, its preservation and the maintenance of the chain of custody are extremely important.

6. VIOLENCE a. Violence directed against ED personnel has become an issue of concern throughout the late 1990s and into the 21st century. The environment inherent in the ED, the emotional circumstances often surrounding the illness or injury that affect both clients and family members, and the increasingly violent trends all play a role in this phenomenon. b. Administrative changes have been made in some EDs to enhance both public and health care worker safety. These measures have included the installation of items such as metal detectors, panic buttons, bullet-proof glass, and lock- down doors at public entrances; increasing the visibility of security guards; using patrol guard dogs; and instituting visitor control policies.

c. Changing the perception of the ED from one of fear and isolation for both clients and family members is also occurring. d. Instituting family centered practices that recognize tile importance of family participation and addressing the emotional needs of clients and families is a trend in ED management. Following are areas to address Recognizing potentially violent clients and situations Identifying verbally and physically abusive signs from clients, family members, or friends Understanding the importance of instinct or gut , reactions Using simple communication strategies to defuse potentially problematic situations Requiring clients to completely undress before physical examination Minimizing the presence of potential weapons in client care areas such as scalpels, needles, excess tubing attached to oxygen flow meters, scissors, stethoscopes worn around the neck, and personal jewelry. Restraining clients, when necessary, using a team approach. Avoiding becoming a hostage in a volatile situation Having safety committee track all reported assaults on clients and employees Ensuring Occupational Safety and Health Administration violence guidelines are followed Encouraging employees to report both verbal and physical assaults. B. ETHICAL ISSUES 1. UNEXPECTED DEATH a. When death occurs in the ED setting, it is usually sudden and unexpected, even if the client has had a prolonged illness. I hr unexpected nature of the death, or impending death, can present ethical dilemmas for both the family survivors and the ED personnel.87 One such issue deals with the length to which resuscitation is performed. This is usually a physicians decision; however, family members may at times have input. Allowing family members or significant others to be present during client resuscitation is becoming more common. This practice is not necessarily disruptive to the resuscitation process, and it can be of comfort to the survivors and the involved ED personnel. b. When death does occur, the ED nurse and the ED physician have important roles in informing the family: i. Inform the family of the clients death, and refer to the deceased client by name. ii. Provide the family with an explanation of the course of events related to the death; use simple explanations.

iii. Offer the family an opportunity to view the body. If a child has died, allow the parent to hold the child. Providing the parent with a lock of the childs hair may be comforting. iv. Help the family to focus on decisions requiring immediate attention such as taking possession of the deceased persons valuables, arranging postmortem examination if desired or required, identifying possible organ or tissue donation, and selecting a funeral home. v. Inform family members when they can leave the ED setting. vi. Provide community agency referral as needed. 2. ORGAN AND TISSUE DONATION Issues related to potential organ or tissue donation often arise in the ED setting. Once a potential donor is identified, the surviving family members need to be approached. A team approach involving a physician, a nurse, arid possibly an organ procurement coordinator is optimal. Utmost dignity and professionalism must be maintained. Whatever decision the family makes regarding organ or tissue donation, that decision must be supported by health Care personnel. 3. CHILD ABONDONMENT a. States are beginning to pass child abandonment laws in response to the number of newborn infants being abandoned following birth. In general, the law allows mothers to bring their newborn child to the ED and abandon the child in the care of the ED personnel. The mother bears no criminal responsibility. Local Departments of Social Services are then contacted so the child can be placed in their custody. PRINCIPLES OF EMERGENCY CARE A. TRIAGE Triage, a French word meaning to sort, refers to the process of rapidly determining patient acuity. It is one of the most important assessment skills needed by the emergency nurse.1 The triage process is based on the premise that patients who have a threat to life, vision, or limb should be treated before other patients. A triage cistern identifies and categorizes patients so that the most critical are treated first. After the emergency nurse completes the initial assessment to determine the presence of actual or potential threats to life, appropriate interventions are initiated for the patients condition. A history is obtained simultaneously with the assessment. A systematic approach to the initial patient assessment decreases the time required to identify potential threats and minimizes the risk of overlooking a life-threatening condition. Two systematic approaches, a primary survey and a secondary survey, were initially developed for use with the trauma patient, but these can be easily applied to assessment of any emergency patient.

B. PRIMARY SURVEY The primary survey focuses on airway, breathing, circulation, and disability and serves to identify life-threatening conditions so that appropriate interventions can be initiated. Lifethreatening conditions related to airway, breathing, circulation, and disability may be identified at any point during the primary survey. When this occurs, interventions are started immediately and before proceeding to the next step of the survey. A =Airway with Cervical Spine Stabilization and/or Immobilization. 1. Nearly all immediate trauma deaths occur because of airway obstruction. Saliva, bloody secretions, vomitus, laryngeal trauma, dentures, facial trauma, fractures, and the tongue can obstruct the airway. Patients at risk for airway compromise include those who have seizures, near-drowning, anaphylaxis, foreign body obstruction, or cardiopulmonary arrest. If an airway is not maintained, obstruction of airflow occurs and hypoxia, acidosis, and death may result. 2. Primary signs and symptoms in a patient with a compromised airway include dyspnea, inability to vocalize, presence of foreign body in the airway, and trauma to the face or neck. Airway maintenance should progress rapidly from the least to the most invasive method. 3. Treatment includes opening the airway using the jaw-thrust maneuver (avoiding hyperextension of the neck), suctioning and or removal of foreign body, insertion of a nasopharyngeal or an oropharyngeal airway (will cause gagging if patient is conscious), and endotracheal intubation. if unable to intubate because of airway obstruction, an emergency cricothyroidotomy or tracheotomy should be performed. Patients should be ventilated with 100% oxygen using a bag valve mask (BVM) device before intubation or cricothyroidotomy. 4. Rapid sequence intubation is the preferred procedure for securing an unprotected airway in the ED. It involves the use of sedation (e.g. etomidate) and paralysis (eg.. succinylcholine) to facilitate intubation while minimizing the risk of aspiration and airway trauma. 5. Any patient with face, head, or neck trauma and or on significant upper torso injuries should always be suspected of cervical spine a neutral position) and or immobilized during assessment of the airway. At the scene of the injury, the cervical spine is immobilized with a rigid cervical collar or a cervical immobilization device (CED) (also known as head blocks). Towel rolls are taped to a backboard on either side of the head. Finally, the patients forehead is secured to the backboard. Sandbags should not be used because the weight of the bags could move the head if the patient must be log-rolled. B =Breathing. 1. Adequate airflow through the upper airway does not ensure adequate ventilation. 2. Breathing alterations are caused by many conditions, including fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, and asthma attacks.

3. Patients with these conditions may experience a variety of signs and symptoms, including dyspnea (e.g., pulmonary emboli), paradoxic or asymmetric chest wall movement (e.g. flail chest), decreased or absent breath sounds on the affected side (e.g. pneumothorax) visible wound to chest wall (e.g., penetrating injury), cyanosis (e.g., asthma), tachycardia, and hypotension. 4. Every critically injured or ill patient has an increased metabolic and oxygen demand and should have supplemental oxygen. 5. High flow oxygen (100%) via a non-re-breather mask should be administered and the patients response monitored. Life-threatening conditions, such as tension pneumothorax and flail chest, can severely compromise ventilation, Interventions in these situations include BVM ventilation with 100% oxygen, intubation, and treatment of the underlying cause. C = Circulation. 1. An effective circulatory system includes the heart, intact blood vessels, and adequate blood volume. 2. Uncontrolled internal and/or external bleeding places a person at risk for hemorrhagic shock. 3. A central pulse (e.g., carotid) should be checked because peripheral pulses may be absent as a result of direct injury or vasoconstriction. 4. If a pulse is palpated, the quality and rate of the pulse are assessed. 5. Skin should be assessed for color, temperature, and moisture. 6. Altered mental status is the most significant signs of shock. 7. Care must be taken when evaluating capillary refill in cold environments because cold delays refill. 6. Intravenous (IV) lines are inserted into veins in the upper extremities unless contraindicated, such as in a massive fracture or an injury that affects limb circulation. 7. Two large-bore (14- to 16-gauge) IV catheters should be inserted and aggressive fluid resuscitation initiated using normal saline or Ringers lactate solution. 8. Direct pressure with a sterile dressing should be applied to obvious bleeding sites. Blood samples are obtained for typing to determine ABO and Rh group. 9. Type specific packed red blood cells should be administered if needed. In an emergency (life-threatening) situation, uncrossmatched blood may be given if immediate transfusion is warranted. 10. The use of the pneumatic antishock garment (PASG) is a temporary strategy that may be considered for pelvic fracture bleeding with hypotension.4 The PASG is a three-chambered suit that is applied to the patients legs and abdomen and is inflated with a foot pump. Physiologically, the PASG increases peripheral vascular resistance in the patients lower extremities, thus elevating blood sure, and works to control pelvic fracture bleeding. 11. Care must taken when deflating the garment. Rapid deflation can result in a severe drop in peripheral vascular resistance and blood pressurealternative devices to the PASG include pelvic splints and belts.

D = Disability. 1. A brief neurologic examination completes the primary survey. The degree of disability is measured by the patients level of consciousness. Determining the patients response verbal and/or painful stimuli is one approach to assessing level consciousness. A simple mnemonic to remember is AVPU: A = alert, V = responsive to voice, P = responsive to pain, and U unresponsive. 2. In addition, the Glasgow Coma Scale is used to assess the arousal aspect of the patents consciousness. 3. Finally, the pupils should be also assessed for size, shape, response to light, and equality. C. SECONDARY SURVEY After each step of the primary survey is addressed and any lifesaving interventions are initiated, the secondary survey begins. The secondary survey is a brief, systematic process that is aimed at identifying all injuries. E=Exposure/Environmental Control All trauma patients should have their clothes removed so that a thorough physical assessment can be performed. Once the patient is exposed, it is important to limit heat loss and prevent hypothermia by using warming blankets, overhead warmers, and warmed IV fluids. F=Full Set of Vital Signs/Five Interventions/Facilitate Family Presence. 1. A complete set of vital signs, including blood pressure, heart rate, respiratory rate, and temperature, should be obtained after the patient is exposed. 2. Blood pressure should be obtained in both arms if the patient has sustained or is suspected of having sustained chest trauma, or if the blond pressure is abnormally high or low. 3. At this point, it must be determined whether to proceed with the secondary survey or to perform additional interventions. The availability of other team members often influences this decision. For patients who have sustained significant trauma and/or have required lifesaving interventions during the primary survey, the following five interventions should be performed at this time: a. The patient should he monitored h electrocardiogram (ECG) for heart rate and rhythm. b. The pulse oxymetry should ho initiated and oxygen saturation (Sp02) monitored. c. An indwelling catheter should be inserted to monitor urine output and to check for hematuria, An indwelling catheter should not be inserted if a urethral tear is suspected. Patients with pelvic injuries, with blood at the meatus, or who are unable to void, and men with a high-riding prostate gland on digital rectal examination, are at risk for a urethral tear or transection. A retrograde urethrogram should be obtained before a catheter is inserted.

d. An Orogastric or a nasogastric tube should be inserted to provide gastric decompression and emptying to reduce the risk of aspiration and to test the contents for blood. A nasogastric tube should not be placed in the nares of a patient suspected of having facial fractures or a basilar skull fracture because the tube could enter the brain through the cribriform plate; rather, it should be placed orally. e. Laboratory studies for typing and crossmatching, hematocrit, hemoglobin, blood urea nitrogen, creatinine, blood alcohol, toxicology screening, arterial blood gas (ABGs), electrolytes, coagulation profile, liver enzymes, cardiac enzymes, and pregnancy should be facilitated. Facilitating family presence (FP) completes this step of the secondary survey. Research supports the benefits of FP during resuscitation and invasive procedures to patients, families, and staff. Patients reported that having family members present comforted them, served as an advocate for them, and helped to remind the health care team of their personhood. Family members who wished to be present during invasive procedures and resuscitation viewed themselves as active participants in the care process. They also believed that they provided comfort to the patient and that it was their right to be with the patient. Staff nurses reported that family members who participated in FP functioned as patient helpers (e.g. providing support) and staff helpers (e.g., acting as a translator) and reinforced that FP helped to convey the sense of the patients personhood. Should a family member request FP during resuscitation or invasive procedures, it is essential that a member of the team he designated to explain care delivered and be available to answer questions. G = Give Comfort Measures. 1. Provision of comfort measures is of paramount importance when caring for patients in the ED. It has been reported that pain is the primary complaint of all patients who come to the ED. 2. Many EDs have developed nurse-initiated pain management protocols to treat pain early, beginning at triage. Pain management strategies should include a combination of pharmacologic (e.g. nonsteroidal anti-inflammatory drugs, IV opioids) and nonpharmacologic (e.g., imagery, distraction) measures. 3. Emergency nurses play a pivotal role in ongoing pain management because of their frequent contact with patients. General comfort measures such as verbal reassurance, listening, reducing stimuli (e.g., dimming lights), and developing a trusting relationship with the patient and family should he provided to all patients in the ED. H = History and head-to-toe assessment 1. History should include following questions a. What is the chief complaint? b. What caused the patient to seek attention?

c. What are the patient subjective complaints? d. What is the patients description of pain (e.g.. location, duration. quality, character)? e. What are witnesses (if any) descriptions of the patients hehaior since the onset? f. What is the patients health history? The mnemonic AMPLE is a memory aid that prompts the nurse to ask about the following: A = Allergies M = Medication history P = Past health history (e.g., preexisting medical and/or psychiatric conditions, previous hospitalizations/surgeries, smoking history, recent use of drugs/alcohol, tetanus immunization, last menstrual period, baseline mental status). L= Last meal E= Events/environment preceding illness or injury 2. Head, Neck, and Face The patient should be assessed for general appearance, skin color, and temperature. The eyes should be evaluated for extraocular movements. A disconjugate gaze is an indication of neurologic damage. Battles sign, or bruising directly behind the ear(s), may indicate a fracture of the base of the posterior portion of the skull. Raccoon eyes, or periorbital ecchymosis, is usually an indication of a fracture of the base of the frontal portion of the skull. The tympanic membranes and external canal are checked for blood and cerebrospinal fluid. Clear drainage from the ear or nose should not be blocked. The airway is assessed for foreign bodies, bleeding, edema, and loose or missing teeth. Assess for difficulty swallowing, movement. The trachea is palpated and visualized to determine whether it is midline. A deviated trachea may signal, a life-threatening tension pneumothorax. Subcutaneous emphysema may indicate laryngotracheal disruption A stiff or painful neck area may signify a fracture of one or more cervical vertebrae. The cervical spine must be protected using a rigid collar and supine positioning. Patients must be logrolled while maintaining cervical spine immobilization when movement is necessary. 3. Chest.

The chest is examined for paradoxic chest movements and large sucking chest wounds. The sternum, clavicles, and ribs are palpated for deformity and point tenderness. The chest is assessed for pain on palpation, respiratory distress, decreased breath sounds, distant heart sounds, and distended neck veins In addition to tension pneumothorax and open pneumothorax, the patient should be evaluated for rib fractures, pulmonary contusion, blunt cardiac injury, and haemothorax. A 12-lead ECG should be obtained, particularly on a patient with known or suspected heart disease. The ECG should be done to detect dysarrhythmias and evidence of myocardial ischemia or infarction.

4. Abdomen and Flanks. The abdomen and flanks are more difficult to assess. Frequent evaluation for subtle changes in the abdominal examination is essential. Motor vehicle collisions and assaults can cause blunt trauma. Penetrating trauma tends to injure specific, solid organs (e.g., spleen). Decreased bowel sounds may indicate a temporary paralytic ileus. Bowel sounds in the chest may indicate a diaphragmatic rupture. The abdomen is percussed for distention e.g. tympany (excessive air), dullness [excessive fluid]) and palpated for peritoneal irritation. Intra-abdominal hemorrhage is suspected, a focused abdominal sonography for trauma (FAST) to determine the presence of blood in the peritoneal space (hemoperitoneum) is preferred. This procedure is noninvasive and can be performed quickly at the bedside. An alternative, a diagnostic peritoneal lavage, may be considered. Before this procedure, a gastric tube and a bladder catheter must be inserted to decompress these organs and reduce the possibility of perforation. 5. Pelvis and Perineum. The pelvis is gently palpated, not rocked. If pain is elicited, it may indicate a pelvic fracture. The genitalia are inspected for bleeding and obvious injuries. A rectal examination is performed to check for blood, a high-riding prostate gland, and loss of sphincter tone. Assess for bladder distention, hematuria, dysuria, or the inability to void. 6. Extremities. The upper and lower extremities are assessed for point tenderness, crepitus, and deformities. Injured extremities are splinted above and below the injury to decrease further soft tissue injury and pain.

Grossly deformed, pulseless extremities should be realigned and splinted. Pulses are checked before and after movement or splinting of an extremity. A pulseless extremity is a time-critical vascular or orthopedic emergency. Extremities are also assessed for compartment syndrome. This occurs as pressure and swelling increase inside a section of an extremity (e.g., anterior compartment of lower leg), compromising the viability of the extremity muscles, nerves, and arteries. I = Inspect the posterior surface Inspect the Posterior Surfaces. The trauma patient should always be logrolled (while maintaining cervical spine immobilization) to inspect the patients posterior surfaces. The back is inspected for ecehymoses, abrasions, puncture wounds. cuts, and obvious deformities. The entire spine is palpated for misalignment, pain, deformity.

INTERVENTION AND EVALUATION Once do secondary survey is complete, all findings are recorded. All patients should Be evaluated to determine their need for tetanus prophylaxis. Information about the patients past vaccination history and the condition of any wounds is needed in order to make an appropriate decision. Regardless of the patients chief complaint, ongoing patient monitoring and evaluation of interventions are critical in an emergency situation. The nurse is responsible for providing appropriate interventions and assessing the patients response. The evaluation of airway patency and the effectiveness of breathing will always assume highest priority. The nurse will monitor 02 saturation and ABGs to help determine the patients progress in these areas. Level of consciousness, vital signs, quality of peripheral pulses, urine output, and skin temperature, color, and moisture provide key information about circulation and perfusion and are also closely monitored. Depending on the patients injuries and/or illness, the patient may be (I) transported for diagnostic tests such as X-ray or CT scan: (2) admitted to a general unit, telemetry, or an intensive care unit; or (3) transferred to another facility. The emergency nurse is responsible for monitoring the critically ill patient during intrafacility and interfacility transport and notifying the team should tile patients condition change from baseline. Nurses accompanying patients on transports must be competent in advanced lifesupport measures.

Death in the Emergency Department

Unfortunately, there are a number of emergency patients who do not benefit from the skill, expertise, and technology available in the ED. It is important for the emergency nurse to be able to deal with feelings about sudden death so that the nurse can help families and significant others begin the grieving process. The emergency nurse should recognize the importance of certain hospital rituals in preparing the bereaved to grieve, such as collecting the belongings, arranging for an autopsy, viewing tile body, and making mortuary arrangements. The death must seem real so that the significant others can begin to grieve and accept tile death. The

emergency nurse plays a significant role in providing comfort to tile surviving loved ones after a death in the ED. Many patients who die in tile ED could potentially be a candidate for nonheart beating donation. Certain tissues and ure:iiis such as cornea, heart valves, skin, bone, and kidneys can be harvested from patients after death. Approaching families about donation after an unexpected death is distressing to both the staff and the family. For many families, however, the act of donation may be the first positive step in the grieving process. Organ are available to assist in the process of screening potential donors, counseling donor families, obtaining informed consent, and harvesting organs from patients who have died in the ED.