Module

Topic 1

 Special population assessment There are several patient populations that warrant the emergency nurse’s heightened knowledge. These groups have physiological and psychological factors that require an adapted approach to assessment and additional management considerations. These populations include: Bariatric, Paediatric, Neonate, Geriatric, Intoxicated, Interpersonal Violence, the Child at Risk, Obstetric, Mental Health and Oncology patient. There are several chapters in the prescribed textbook that specifically discuss in detail these patient characteristics and implications for the ED nurse. The following readings compliment those chapters and provide additional information that will assist you in the Activity 4 and the exam content. Readings

 Corrales, A.Y. & Starr, M. (2010), Assessment of the unwell child, reprinted from Australian Family Physician, 39 (5)

 May. Hoover, R.M. & Polson, M. (2014). Detecting elder abuse and neglect: Assessment and intervention. American Family Physician, 89 (6): 453-460.

 Martonffy, A.I., Rindfleisch, K., Lozeau, A.M. & Potter, B. (2012). First trimester complications. Primary Care Clinical Office Practitioner, 39: 71-82.

 NSW Department of Health. (2011). Recognition of a Sick Baby or Child in the Emergency Department. North Sydney, Australia: NSW Department of Health http://www1.health.nsw.gov.au/PDS/pages/doc.aspx?dn=PD2011_038 Accessed online August 2017

 Peck, K.A., Calvo, R.Y., Schechter, M.S, Sise, C.B., Kahl, J.E., Shackford, M.C…….Blaskiewicz, D.J. (2014). The impact of pre-injury anticoagulants and prescription antiplatelet agents on outcomes in older patients with traumatic brain injury. Journal of Trauma and Acute Care Surgery, 76 (2): 431-436.

 Shaveeres, G.A. (2012). Intimate partner violence: A guide for primary care providers. The Nurse Practitioner, 38 (12): 39-46.

 Activity 1 – Special population assessment  (4 hours)

Write a paragraph to highlight the three most significant considerations when assessing the following patients. Consider physiological, psychological or historical information.

1. A 3 day old baby with peri orbital cellulitis.

2. An intoxicated young male with a laceration to the back of his head, poor historian

3. A 38 week pregnant woman involved in a low speed motor vehicle collision

4. A 200kg person with shortness of breath

5. An 85 year old with decreased mobility and falls

6. A 2 year old toddler, pale, sitting quietly on mums lap during assessment

7. 54 year male with a temperature of 39.5 Celsius and is presently receiving chemotherapy 8. A 24 year old female with wrist injury and 2 children. The presentation is inconsistent with the history given, and the partner refuses to leave triage.

 

 

 

Topic 2: Clinical Indicators of alteration in major systems functions and their physiological impact (including deterioration).

Emergency practice requires nurses to blend theoretical knowledge systems, past experiences, collated patterns of knowing and ways of doing with a patient’s physiological, interpersonal and communicative signs (Fry 2007). Convergences of these knowledge systems with cognitive domains that include assessment, diagnosis, treatment and evaluation skills enable greater accuracy and speed for decision-making and the troubleshooting, prioritisation and delivery of emergency care. Understanding the clinical Indications or signs of alteration in major systems functions and their resultant physiological impact assists the ED nurse to further prioritise.

Readings

Fry, M. (2011). Ch 1. Overview of emergency care in Australia in Trauma Care for Nurses and Paramedics, In K. Curtis & C. Ramsden (Ed), Emergency and trauma care for nurses and paramedics. Sydney, Australia: Elsevier.

 

 

Activity 2 – Clinical alterations and their physiological impact (2.5 hrs)

For each of the following body systems, describe at least 3 clinical symptoms which could indicate alteration in their function. Provide potential causes for that alteration, and explain the physiological impact that alteration can have on the body.

Body systems: Cardiovascular (eg as below), Respiratory (eg wheeze), Fluid & electrolyte (eg decreased urine output), Neurological (eg facial droop), Mental health (eg hallucinations)

 

For example: Cardiovascular System:

 

 

 

Topic 3: Triage

Australasian triage guidelines were developed to assist the nurse to discriminate between life-threatening, urgent and non-urgent conditions. However, triage involves more than the application of a triage guidelines. Triage Nurses determine the need for a bed, allocate ED resources, fast track patient care, deliver first aid and provide a safety net for waiting patients. Today to undertake triage and meet additional role demands nurses require extensive emergency experience, and advanced practice and decision-making skills (Fry 2007).

 

Triage activities will occur on the study day. Please be familiar with the following material prior to the study day, in particular the Emergency Triage Education Kit (ETEK).

Readings

Emergency Triage Education Kit, Department of Health and Ageing, Australian Government, October 2007: Available online: http://www.health.gov.au/internet/main/publishing.nsf/Content/casemix-ED-triage+Review+Fact+Sheet+Documents accessed August 2017

Fry, M. (2011). Triage Ch13 in Trauma Care for Nurses and Paramedics, In K. Curtis & C. Ramsden (Ed), Emergency and trauma care for nurses and paramedics. Sydney, Australia: Elsevier.

McCallum Pardey, T G. (2006). The clinical practice of Emergency Department Triage: Application of the Australasian Triage Scale- An extended literature review. Part 1. Evolution of the ATS Australasian Emergency Nursing Journal, 9: 155-162.

It is also important to identify potential risk/trends and apply strategies to particular patient presentations, for example multiple presentations of patients with similar symptoms

 

 

Activity 3  – Prioritising  (2 hours)

Think back to the most recent shift where you had a patient load in the acute care setting and were receiving handover. Make a list/table of the patients you were allocated (give them a letter, for example, patient A – abdominal pain).

 

 

 

1. Describe how you assessed each patient (using table format)

2. What could potentially go wrong for that patient?

3. What would be the clinical indicators that they were deteriorating?

4. What else would alter your prioritisation order?

5. In a paragraph, how did you prioritise the interventions required for those patients, please explain your rationale.

 

 

 

Topic 4: Systematic patient assessment in the Emergency Department

When faced with uncertainty around the patient’s underlying problem it is important to have a systematic approach to patient assessment. Figure 1 illustrates the relationship between the five steps of the assessment process: history; red flags; assessment; interventions; and investigations. While each of these steps is discussed separately below, it is important to remember that often these steps might be undertaken simultaneously, and evaluation and reassessment is essential. It is also key to be anticipating the patient’s ultimate destination in order to facilitate patient flow and definitive care.

 

Step 1: History

In determining the severity of the patients’ illness and need for intervention it is important to begin determining the patient’s individual health history. When taking a patient’s history some of the key points include:

 Pain history

 Associated symptoms

 Past medical history / past surgical history

 Medication history

 Allergies

 Last menstrual period

 Significant events in past 24 hours / mechanism of injury

 

These key points should guide your questioning of the patient and/or their family so that you obtain comprehensive information about the patient’s history. During history taking it is important that you do not make assumptions about the patient’s clinical presentation until you have completed a comprehensive assessment. For example, you can’t dismiss underlying cardiac pathology in the patient with pleuritic chest pain without conducting a thorough assessment. The pleuritic chest pain may be masking other symptoms, or the patient may have two clinical conditions.

Step 2: Potential ‘red flags’

The clinical environment of the emergency department is both challenging and exciting. In this clinical are you will encounter a diverse group of patients across the spectrum of disease and age, and with differing and unexpected medical needs. The first priority is to establish the severity of threat to life or limb and hence the need for medical intervention. Many times this determination is made within seconds of the emergency nurse’s encounter with a patient. Examples of this may be severe central crushing chest pain, major trauma or imminent cardiac arrest. However consider the 80 year old nursing home resident with a fever, the 35 year old diaphoretic male with shortness of breath, and a past history of asthma that required intensive care management 1 year ago. Both of these patients may be critically ill and require immediate medical intervention. As an emergency nurse you must be able to recognise the sick or potentially sick patient so that this patient can be immediately prioritised within the busy emergency department.

In determining the severity of the patient’s illness and the need for immediate intervention, the emergency nurse relies on a combination of clinical signs and historical factors. Findings that may indicate severe illness include abnormal vital signs, a medical history of ischaemic heart disease, or time sensitive presentations (such as chest pain or the onset of acute neurological signs). These can be referred to as clinical or historical indicators of urgency also termed “red flags”. Clinical indicators are discussed as part of Step 3. Historical red flags are obtained when you are listening to the patient’s history. For example, those high risk symptoms in a patient’s medical history, such as a past history of cardiac disease, or hypertension are historical red flags in the patient presenting with chest pain. Don’t make assumptions until you have ruled out all high morbidity and mortality conditions. Assess each patient using the ‘worst first’ mentality, that is,

consider the worst possible cause of the clinical presentation. For example, for patients presenting with chest pain, it is imperative that potential life threatening conditions are identified or eliminated first. Another example is the motto “trauma patients have a cervical spine injury until proven otherwise”.

Step 3: Clinical examination

The next step of the assessment process is the clinical examination. Clinical examination of a patient involves not just physical examination, but also the collection of data through diagnostic or laboratory tests. Issues related to social and environmental history are important to include as well. When completing the case study below, remember to identify clinical indicators of urgency or ‘red flags’.

Step 4: Investigations

The availability of diagnostic and laboratory testing assists with identifying the path to definitive care for patients admitted to the emergency department. The availability of diagnostic and laboratory tests is dependent on their availability in the health care organisation. Most major metropolitan hospitals will have 24-hour access to such facilities however patients admitted to rural and/or remote emergency departments (or even smaller metropolitan emergency departments) may have limited access to laboratory and diagnostic tests, particularly after hours. While the responsibility for determining which diagnostic and laboratory tests might be required is not a primary nursing responsibility it is critical that nurses understand why particular tests might be required and the significance of the results.

Step 5: Nursing Interventions

As this whole assessment process is interactive and fluid, many things may occur simultaneously. For example while you are assisting your patient (who has just arrived at their bed) to put on a hospital gown, you will be asking historical questions, taking note of their mobility or difficulty speaking, any language barriers and any skin alterations. During this patient assessment, patient needs will become apparent and you may identify opportunities to initiate simple and effective interventions, such as the administration of analgesia, the application of oxygen therapy or the need for the insertion of an intravenous cannula and collecting of blood. These can be performed concurrently.

The following activity allows you to apply the assessment framework described above to a case study where there might be uncertainty about the patient’s clinical presentation.

 

 

Activity4: Case Study (1 hour)

A 63 year-old man presents to the emergency department. The patient says that he earlier today he experienced 30 minutes of chest pain while walking to the shops. At this time he also experienced shortness of breath and felt ‘sweaty’. Using the framework provided above, use each of the five steps to assess the patient. Post your answers on e-learning under the topic “Patient Assessment”. It is important to practice this approach to patient assessment so that it becomes second nature, which will aid your time management and prioritisation skills in the busy emergency department.

§ What questions will you ask?

 

 

§ What historical and clinical indicators will you be trying to identify and be concerned about as “red flags” in the patient with chest pain?

§ Describe your clinical assessment and subsequent investigations and nursing interventions.

 

Topic 5 – Sepsis

Infective processes frequently occur in patients both in the community and within the hospital setting. Physiological processes associated with immunity attempt to protect the body from invasion by foreign material. Non-specific immunity, through the process of inflammation, is an important step in preventing the spread of infection. The infective process can occur with varying degrees of severity, from the development of localised infection through to patients who present with septic shock (see Table). When the infection becomes systemic the patient’s clinical presentation can become greatly compromised. It is important to recognise that these physiological processes can also occur as a result of non-infective processes such as trauma, pancreatitis and severe burns. When no infective organism is identified this is referred to as systemic inflammatory response syndrome (SIRS).

 

 

 

In this topic we will be looking specifically at sepsis, severe sepsis and septic shock which can be caused from a variety of different organisms. The following figure shows the relationship between infection, sepsis and SIRS, highlighting some of the causes (Figure 2). Remember that infection is reasonably common and sepsis (and its continuum) is less so. This is because of our complex and reasonably effective immune response. However, when an aggressive organism targets a vulnerable patient, such as

those who are immunocompromised, the elderly and young children, the development of sepsis is more likely.

Figure 2: The interrelationship between sepsis, SIRS and infection

 

 

 

 

Each of these processes are associated with complex physiological alterations that impact negatively on tissue perfusion and oxygenation. Despite advances in antibiotic therapy and improvements in our understanding of the physiological processes that occur in septic patients, the incidence continues to increase and associated mortality has not greatly improved. Patients who present with sepsis, severe sepsis or septic shock have complex physiological derangements that impact on cellular oxygenation and consequently energy production. While the physiological changes that occur in sepsis are complex, the main responses result in vasodilation, increased capillary permeability and microvascular occlusion, each which individually and collectively contributes to decreased cellular oxygenation.

Recognition of those patients at risk for the development of sepsis as well as the clinical signs that are suggestive of a shocked state is an important part of the emergency nurses’ role so that early and definitive treatment can be initiated. To build on and apply your existing knowledge of shock to the specific clinical conditions of sepsis and septic shock read the following chapter from your prescribed textbook.

Reading

Howell, M.D. & Davis, A.M. (2017). Management of sepsis and septic shock. Journal American Medical Association. Published online January 19, 2017.

doi:10.1001/jama.2017.0131 Available online 29/01/17: http://jamanetwork.com/journals/jama/fullarticle/2598892

Kraut, J.A. and Madias, N.E. (2014). Lactic acidosis. New England Journal of Medicine, 371, 2309-2319.

PenolaGordon, C. &Craft, C. (2015). Homeostasis. In J. Craft, C. Gordon, S.E. Heuther, K.L. McCance, V.L. Brashers & N.S. Rote, (Eds). Understanding Pathophysiology (2nd ed) (pp.665-682). Sydney: Elsevier Australia.

Verrinder, A. & Kinsman, L. (2011). Physiology for Emergency Nurses. In K. Curtis & C. Ramsden (Ed), Emergency and trauma care for nurses and paramedics. Sydney, Australia: Elsevier.

Effective management of patients who present with sepsis or septic shock involves the identification of the causative organism so steps to facilitate its removal. While antibiotics are commonly prescribed and may help with preventing bacteria from multiplying or destroying the bacteria there are times when surgical intervention may be necessary to remove the causative organism. Because sepsis and septic shock has great potential to cause haemodynamic instability, it is also important to support the patient’s haemodynamic status and end-organ perfusion. The following reading uses a case study approach to illustrate some of the common strategies to supporting patients with sepsis. As you read through this article keep in mind that patients who have severe sepsis or septic shock may require ongoing intensive care management. Some of the therapies discussed in this article you may have little or no experience with, for example, central venous pressure monitoring and the use of pulmonary artery catheters to measure mixed venous oxygen saturation (ScvO2), however the article provides a comprehensive overview of the most common strategies for managing sepsis.

Reading

Coggins, A. (2017). Sepsis and septic shock: Recognise, resuscitate and refer (summary of recommendations).EmergencyPedia https://emergencypedia.com/2017/01/23/new-sepsis-guidelines-2017/ Accessed online August 2017.

Kleinpell, R., Aitken, L., & Schorr, C. A. (2013). Implications of the new international

sepsis guidelines for nursing care. American Journal of Critical Care, 22(3), 212-222.

PenolaGordon, C. &Craft, C. (2015). Homeostasis. In J. Craft, C. Gordon, S.E. Heuther, K.L. McCance, V.L. Brashers & N.S. Rote, (Eds). Understanding Pathophysiology (2nd ed) (pp.665-682). Sydney: Elsevier Australia.

Rhodes, A., Evans, L.E., Alhazzani, W., Levy, M.M., Antonelli, M., Ferrer, R., ……Dellinger, R.P. (2017). Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2016. Critical Care Medicine, 45:486–552.

Activity5  (2.5 hours)

In the course of your clinical practice, identify a patient who presents with sepsis, severe sepsis or septic shock. Having read the above article, present a short case study including information on the following:

 Patient history and presenting complaint, including historical “red flags” or risk factors

 Physical assessment findings of “red flags” that are suggestive of sepsis, severe sepsis or septic shock

 Your initial and ongoing nursing interventions and methods of evaluating them

 Results of any diagnostic or laboratory tests

 Medical and nursing strategies to improve patient outcome

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