Scope and Practice 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 emer-gency nurse establishes priorities, monitors and continuously as-sesses acutely ill and injured patients, supports and attends to families, supervises allied health personnel, and teaches patients and families within a time-limited, high-pressured care environ-ment. Nursing interventions are accomplished interdependently, in consultation with or under the direction of a licensed physi-cian or nurse practitioner. The strengths of nursing and medicine are complementary in an emergency situation. Appropriate nurs-ing and medical interventions are anticipated based on assess-ment 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 patient’s condition. Although a patient may have several diagnoses at a given time, the focus is on the most life-threatening ones; often, both independent and interdependent nursing interventions are required.
Emergency nursing is demanding because of the diversity of con-ditions and situations that, if not unique to the ED, certainly pre-sent a challenge (Chart 71-1). These issues include legal issues, occupational health and safety risks for ED staff, and the chal-lenge of providing holistic care in the context of a fast-paced, technology-driven environment in which serious illness and death are confronted on a daily basis. Another dimension of emergency nursing is nursing in disasters. With the increasing use of weapons of terror and mass destruction, the emergency nurse must expand his or her knowledge base to encompass recognizing and treating patients exposed to biologic and other terror weapons and anticipate nursing care in the event of a mass casualty inci-dent.
Consent to examine and treat the patient is part of the ED record. The patient must consent to invasive procedures (eg, angiogra-phy, lumbar puncture) unless he or she is unconscious or in crit-ical condition and unable to make decisions. If the patient is unconscious and brought to the ED without family or friends, this fact should be documented. Monitoring of the patient’s con-dition, as well as all instituted treatments and the times at which they were performed, must be documented. After treatment, a notation is made on the record about the patient’s condition on discharge or transfer and about instructions given to the patient and family for follow-up care.
Because of the increasing numbers of people infected with hep-atitis B and with human immunodeficiency virus (HIV), health care providers are at an increased risk for exposure to communi-cable diseases through blood or other body fluids. This risk is fur-ther compounded in the ED because of the common use of invasive treatments in addition to the wide range of patient con-ditions. All emergency health care providers should adhere strictly to standard precautions for minimizing exposure.
The reemergence of tuberculosis, a major health problem, is complicated by multidrug-resistant tuberculosis and by tubercu-losis concomitant with HIV infection. Early identification and adherence to transmission-based precautions for patients who are potentially infectious is crucial. Nurses in the ED are usually fitted with a personal high-efficiency particulate air (HEPA)-filter mask apparatus to use when treating patients with airborne diseases.
The potential for exposure to highly contagious organisms, hazardous chemicals or gases, and radiation related to acts of ter-rorism or natural or manmade disasters present additional risks to ED staff.
Sudden illness or trauma is a stress to physiologic and psycho-logical homeostasis that requires physiologic and psychological healing. Patients and families experiencing sudden injury or ill-ness often are overwhelmed by anxiety because they have not had time to adapt to the crisis. They experience real and terrifying fear of death, mutilation, immobilization, and other assaults on their personal identity and body integrity. When confronted with trauma, severe disfigurement, severe illness, or sudden death, the family experiences several stages of crisis. The stages begin with anxiety and progress through denial, remorse and guilt, anger, grief, and reconciliation. The initial goal for the patient and family is anxiety reduction, a prerequisite to recovering the ability to cope.
Assessment of the patient and family’s psychological function includes evaluating emotional expression, degree of anxiety, and cognitive functioning. Possible nursing diagnoses include anxiety related to uncertain potential outcomes of the illness or trauma and ineffective individual coping related to acute situational crisis. In addition to anxiety, possible nursing diagnoses for the family include anticipatory grieving and alterations in family processes related to acute situational crises.
Those caring for the patient should act confidently and compe-tently to relieve anxiety. Reacting and responding to the patient in a warm manner promotes a sense of security. Explanations should be given on a level that the patient can understand, because an informed patient is better able to cope positively with stress. Human contact and reassuring words reduce the panic of the se-verely injured person and aid in dispelling fear of the unknown.
The unconscious patient should be treated as if conscious. That is, the patient should be touched, called by name, and given an ex-planation of every procedure that is performed. As the patient re-gains consciousness, the nurse should orient the patient by stating his or her name, the date, and the location. This basic information should be provided repeatedly, as needed, in a reassuring way.
The family is kept informed about where the patient is, how he or she is doing, and the care that is being given. Allowing the family to stay with the patient, when possible, also helps allay their anx-ieties. Additional interventions are based on the assessment of the stage of crisis that the family is experiencing. Measures to help fam-ily members cope with sudden death are presented in Chart 71-2.
Anxiety and Denial.During these stages, family members are en-couraged to recognize and talk about their feelings of anxiety. Asking questions is encouraged. Honest answers given at the level of the family’s understanding must be provided. Although denial is an ego-defense mechanism that protects one from recognizing painful and disturbing aspects of reality, prolonged denial is not encouraged or supported. The family must be prepared for the reality of what has happened and what may come.
Remorse and Guilt.Expressions of remorse and guilt may beheard, with family members accusing themselves (or each other) of negligence or minor omissions. Family members are urged to verbalize their feelings until they realize that there was probably little that they could have done to prevent the injury or illness.
Anger.Expressions of anger, common in crisis situations, are away of handling anxiety and fear. Anger is frequently directed at the patient, but it is also often expressed toward the physician, the nurse, or admitting personnel. The therapeutic approach is to allow the anger to be ventilated, then assist the family to identify their feelings of frustration.
Grief.Grief is a complex emotional response to anticipated or ac-tual loss. The key nursing intervention is to help family members work through their grief and to support their coping mecha-nisms, letting them know that it is normal and acceptable for them to cry, feel pain, and express loss. The hospital chaplain and social services staff both serve as invaluable members of the team when assisting families to work through their grief.
As stated previously, one principle underlying emergency care is that the patient will be rapidly assessed, treated, and referred to the appropriate setting for ongoing care. This makes the ED a very temporary point on the continuum of care. Most patients who receive emergency care are discharged directly from the ED to their homes, and emergency nurses must plan and facilitate the patient’s safe discharge and follow-up care in the home and the community.
Before discharge, instructions for continuing care are given to the patient and the family or significant others. All instructions should be given not only verbally but also in writing, so that the patient can refer to them later. Many EDs have preprinted stan-dard instruction sheets for the more common conditions. These instructions are then individualized for each patient. These in-structions may be available in a variety of languages. If they are not available in the language that the patient needs, an inter-preter should be used. Instructions should include information about prescribed medications, treatments, diet, activity, and when to contact a health care provider or schedule follow-up appointments. It is imperative that instructions are written leg-ibly, use simple language, and are clear in their teaching. When providing discharge instructions, the nurse also considers any special needs the patient may have related to hearing or visual deficits.
Before discharge, some patients require the services of a social worker to help them meet continuing health care needs. For pa-tients and families who cannot provide care at home, community agencies (eg, Home Care Nursing Services, Visiting Nurse Asso-ciation) may be contacted before discharge to arrange services. This is particularly important for elderly patients who need assis-tance. Identifying continuing health care needs and making arrangements for meeting these needs can prevent return visits to the ED and readmission to the hospital.
For patients who are returning to extended care facilities and for those who already rely on community agencies for continu-ing health care, communication about the patient’s condition and any changes in health care needs that have occurred must be provided to the appropriate facilities or agencies. This commu-nication is essential to promote continuity of care and to ensure ongoing care to meet the patient’s changing health care needs.
The ED is a common point of entry into the health care system for patients 65 years of age and older. In fact, patients in this age group account for more than 99 million visits to emergency fa-cilities each year (see Chart 71-1). Elderly patients typically arrive with one or more presenting conditions involving the skin, cardio-vascular system, or abdomen. Nonspecific symptoms, such as weakness and fatigue, episodes of falling, incontinence, and change in mental status, may be manifestations of acute, poten-tially life-threatening illness in the elderly person. Emergencies in this age group may be more difficult to manage because elderly patients may have
· An atypical presentation
· An altered response to treatment
· A greater risk of developing complications
The elderly patient may perceive the emergency as a crisis sig-naling the end of an independent lifestyle or even resulting in death. The nurse should give attention to the patient’s feelings of anxiety and fear.
The older patient may have fewer sources of social and finan-cial support in addition to frail health. The nurse should assess the psychosocial resources of the patient (and of the caregiver, if necessary) and anticipate discharge needs. Referrals for support services (eg, to the social service department or a gerontologic nurse specialist) may be necessary.