Contents

Abstract. 3

Introduction:4

Assessment and Initiation of Emergency nursing actions. 5

Identification of nursing needs:6

Prioritizing of patient’s needs:7

Planning for Jason’s needs:8

Collaborative needs. 13

Conclusion:15

References. 16

Abstract

This paper focuses on the skills that a nurse requires when working in the emergency department. It analyzes the case of Jason, a patient who has been brought to the emergency department following a road traffic accident. The assessment of Jason is done using an ABCDE approach. The life threatening needs are identified and handled as the patient is re-assessed. Jason is given care as per the plan of care, which is in an order of priority, as per Maslow’s hierarchy of needs, and the collaborative needs addressed. Needs such as maintenance of airway, monitoring of the cardiovascular system, input-output chart monitoring, hygiene, nutrition and counseling are identified and addressed. The paper concludes that critical, thinking, background knowledge, teamwork and practical skills are very necessary for a critical care setting.

Introduction:

Nurses in the emergency department should have the necessary knowledge to assess and plan care for patients in the department (Jones, Endacott & Crouch, 2003). They should also be conversant with the various needs of the patients, which include physiological, psychological, and social needs. The nurse should have the skills necessary to manage the patient in a holistic manner. The needs can involve legal issues, as is encountered by many nurses working in emergency areas (Riviello, 2010). The nurse should be able to collect specimen that will be used in a forensic investigation and write an assessment of the patient that will be used in the courts. While addressing the patient’s needs, the nurse should be conversant with the needs of the family members and should provide for them during the shift. The case of Jason Crawshaw is an example of a patient with medical, legal and psychological needs that should be addressed by the nurse.

This paper analyzes the assessment of Jason Crawshaw, a patient in the Emergency department, who has suffered a road traffic accident. In the discussion, the assessment and a prioritized plan of care for Jason are explained. The paper will also identify the collaborative needs of the patient (Jason), in the critical care department that the nurse is required to manage. Finally, the paper will discuss collaborative management of Jason, in relation to critical care in the emergency department.

Assessment and Initiation of Emergency nursing actions

The primary assessment of a patient involves ABCDE (Cole, 2009). A involves assessment of the airway. Assessment of Jason would be done by observing the chest for movement, listening for air exiting the mouth and nose, observing the skin color, and then observing if the patient is conversing. In the case of Jason, the airway is open and clear as the patient can speak; he is asking for help and the whereabouts of his brother and the girlfriend.

B involves assessing for breathing. Assessment of the breathing process can be achieved by measuring the respiratory rate, the saturation of oxygen and blood gas analysis (Mallet, Albaran, Richardson, 2013). Breathing can also be assessed by observing the movement of the chest and the use of accessory muscles for breathing. The respiratory rate is 24, which lies within the normal ranges. The saturation of oxygen is 82%, which is below the normal. There is compromised movement on the right side of the chest; there is a likelihood of injury to the sternum, and the patient complains he is unable to breathe. There is a need to provide oxygen to increase the oxygen saturation from 82% to 100%. There is a need to establish a definitive airway due to probable injury to the sternum. The airway is established using an oropharyngeal tube.

C involves assessment of the circulatory system. The circulatory system is assessed by measuring the pulse rate and rhythm, blood pressure, temperature, capillary refill time and the urine output (Mallet, Albaran, Richardson, 2013). The patient’s blood pressure is 140/75 and a pulse of 108. A pulse above the normal range of 60-100 and a high systolic blood pressure may indicate that the patient is anxious. The patient should be sedated to relieve anxiety. An intravenous access had already been established before the patient arrived at the hospital, and the patient was put on 1000ml normal saline. Injuries to the sternum are accompanied by a 40-65% chance of underlying organ injury, most likely the heart or the lungs (Smeltzer, Bare, Hinkle & Cheever, 2010). The heart rhythm should be monitored to rule out injury to the heart.

Disability, ‘D’ is assessed by measuring the level of consciousness, blood sugar levels, and the amount of pain the patient is experiencing and pupillary reaction to light (Mallet, Albaran, Richardson, 2013). Jason scored 13 on the Glasgow coma scale, an indication that he is quite stable. Jason’s pupils are equal and react to light. There is a need to provide some pain medications for the chest pain, which is a consequence of injury to the sternum, as evidenced by bruising over the sternum

Exposing the patient is done to assess for abnormalities of the whole body, and to observe for injuries (Mallet, Albaran, Richardson, 2013). There is a bilateral fractureof the femur. Splints should be applied on both legs to immobilize the fractures. There is a suspected spinal injury. The patient is nursed on a spinal board to prevent further injury to the spine. The patient has a bandage on the forehead and the arm. The nurse should expose the bandages and evaluate the need for suturing to prevent further bleeding and enhance healing. Exposing is also important for checking for any tags that show a medical problem that the patient may have (Carlson, 2009).

Identification of nursing needs:

A nurse working in the emergency department should effectively identify the patient’s needs and plan for the care of the patient. Planning is important in identifying all the patient’s needs and putting them in an appropriate order according to priority. Lack of planning may lead to mismanagement of the patient. This may lead to ineffective planning for the patient (Lipe & Beasley, 2013). Planning for care ensures a more holistic approach, and it also increases the contact time between the patient and the nurses.

Jason has many nursing needs. He has impaired breathing and low saturation of oxygen; his respiratory status needs to be stabilized. The patient may need to have his circulation monitored, and fluids replaced due to the fracture. Jason is complaining of pain, he needs to be given pain medication and any other medication that has been prescribed. Restlessness may inhibit proper healing as there is possible trauma to the cervical spine. Jason wants to leave his bed. There is a need to calm him down. The patient also presents with a likelihood of alcohol intoxication. The nurse needs to manage the airway and prevent hypoglycemia.

The patient is complaining that he needs to pee. There may be a need to fix a urinary catheter in order to relieve the patient. The patient may have superficial wounds that may need to be dressed. He requires a bed bath due to dirt he may have from the accident scene, and to enhance comfort. Psychological support is important following the motor-vehicle crash, and the death of his brother and girlfriend. The patient is thought to have been drunk when driving and did not have a seat belt on. The nurse should collect information for a forensic report prior to cleaning the patient.

The family is in need of care, because of the hospitalization and the loss of their loved one. The nurse should facilitate family meeting the patient; they should, in addition, provide psychological therapy for the family and support throughout the shift.

Prioritizing of patient’s needs:

The nurse is required to prioritize the patient needs using either using the Maslow’s hierarchy of needs or a model for the prioritization of needs. This model was developed by Craven and Hirnle (Lipe and Beasley, 2004). The Maslow’s hierarchy identifies the needs as physiological needs, safety needs, social needs, esteem needs and self-actualization. The most basic needs are placed first on the priority list.

The Craven and Hirnle model organizes priorities into 3 groups: High, Low and Medium. High-priority situations include situations that threaten the life of the patient, such as airway difficulties, and cardiovascular problems. They also include situations that threaten the life of a patient, pain and when the patient is very anxious (Cioffi & Grad, 2001).

Medium priority situations include situations that could lead to consequences that affect the health negatively, by maybe causing emotional trauma (Craven & Hirnle, 2003). Such needs include the preparation for surgery and emotional anxiety, as in the case of Jason, the anxiety of the whereabouts of his sibling and girlfriend. Low Priority situations are those situations that can be resolved with minimal interventions (Craven &Hirnle, 2003).

Planning for Jason’s needs:

Jason has a low saturation of oxygen; he has been put on oxygen and has an oropharyngeal airway because of injury to the sternum which was impairing breathing. The nurse should plan to monitor Jason’s respiratory rate, the partial pressure of oxygen and the expansion of the chest. These are monitored every four hours. The nurse should in addition plan for insertion of a chest tube to relieve pneumothorax that is impairing expansion on the right side of the chest.

Fractures usually lead to the loss of a lot of blood (American Association of Critical Care Nurses, 2006). Jason has bilateral fractures to the Tibia. The Cardiovascular system is compromised because of the bilateral fracture of the tibia. The emergency nurse attending to Jason should plan to monitor the cardiovascular system by monitoring blood pressure and pulse four hourly. Urine output should be monitored six hourly. Alcohol usually increases dehydration, which may further compromise the patient’s condition. The deep lacerations on the forehead and the left arm may cause bleeding that may further compromise the cardiovascular system. It is necessary that the nurse plans to suture the lacerations to prevent bleeding and inhibit infection.

The patient is on fluid therapy. The nurse should plan to continue with the fluid therapy. The nurse should maintain an input-output chart. Side effects of fluid therapy such as overload should be monitored (Harvey & Jordan, 2010). Harvey and Jordan (2010) reiterate that, it is important for a nurse to explain to the patient the undesirable side effects of fluid therapy such as the undesirable urination.

The patient presents with a shirt that is soaked in alcohol, inappropriate behavior, is shouting for help and wants to get off the bed. In addition, he was involved in a road traffic accident. The police suspect that he was drunk at the time of the accident. In such circumstances, alcohol intoxication is likely. The nurse should plan to have the patient’s blood sugars taken and manage any hypoglycemia. In addition, the nurse should plan for suctioning in case the patient vomits. The positioning of the patient is important to prevent choking, and, at the same time, maintain the cervical spine and the spinal column (June & Loise, 2001).

The patient hasa spinal injury. Initial management of spinal cord injury involves immobilization (Emergency Nurses Association, 2005). The nurse needs to immobilize the patient to prevent damage to the spinal cord (McCann, 2002). The nurse should also immobilize the legs because of the fractures. The nurse should plan for a spinal board. In addition, there should be a plan to talk to the patient to allay anxiety so that he stops struggling to get out of bed. There should also be a plan for administering sedatives to calm the patient, and avoid movement. Further, the nurse should plan to assess the neurological system to rule out changes that may signify an injury to the spinal cord. The fractures put the patient at risk of developing embolism, which is a life-threatening condition (Yee, 2010).

Patients in the emergency department usually present with extreme pain (Emergency Nurses Association, 2007). Jason is complaining of Chest pain. The nurse should plan to administer pain medication to relieve pain that may be the cause of the anxiety. The drugs will relieve the pain at the same time it will calm down the patient. The need to pee falls under Maslow’s physiological needs. The nurse should plan to insert a catheter and explain to the patient why he cannot use the toilet and instead has to use a catheter.

The patient has a laceration on the forehead. He is also under the influence of alcohol. All these may alter the level of consciousness of the patient. There should be a plan to continuously monitor the level of consciousness of the patient. Any changes in the scale reading will require a review of the interventions. In the case that the patient’s Glasgow coma scale reading falls below 8, there may be a need for immediate intubation and mechanical ventilation (Emergency Nurses Association, 2007).

Motor vehicle accidents usually lead to superficial lacerations that need to be dressed and covered to prevent infection. The nurse should plan to have these wounds dressed and covered. The bandages he had on his forehead, arms and legs should be removed, and the wounds cleaned again. This is followed by a plan to administer antibiotics to prevent infection.

The patient’s case has some legal factors attached to it, as he was driving while drunk, and did not have a seat belt on, and the accident led to the loss of two lives. The nurse should plan to keep forensic evidence that may be required by the police, such as the clothes soaked in alcohol, and the blood alcohol content. In addition, the nurse should plan to write a forensic report on the patient.

The patient was thrown outside the car. He may have picked up a lot of dirt in the process, hence the need for the bed-bath that will aid in exposing other wounds that may have been overlooked. It will also increase the patient’s comfort and aid relaxation (Enright & Fitzgibbons, 2000).

There should be a plan to meet the nutritional requirements of the patient as per the prescribed regimen. In the case that the nutrition is planned for administration via nasogastric tube or parenteral, there should be a plan to insert a nasogastric tube or insertion of a central line with the help of a physician.

The patient may require some investigations. The nurse should prepare the patient for the   investigations. In case the patient needs surgical intervention, the nurse should plan for preoperative care of the patient: patient counseling and patient preparation for surgery by monitoring the vitals, giving preoperative medication and ensuring investigations such as full haemogram have been performed (Rojana, 2004).

Once the patient is stabilized, and the high-priority needs have been met, the nurse should plan for the medium priority needs. The patient was involved in a traumatic experience and risks paralysis. The patient needs counseling on the possible outcome of his condition. He has also lost his brother and girlfriend. The nurse should plan to inform the patient on the loss of his sibling and girlfriend in such a way that it may not lead to depression.

Traumatic events may lead to self-blame or blaming others (Enright & Fitzgibbons, 2000). Enright and Fitzgibbons (2000) insist that it is important to initiate forgiveness of self, or others. This can be achieved through talking to the patient about the experience and discussing the negative impact of not dealing with a traumatic experience effectively (Ahrens, 2002).

Nursing usually involves holistic care. The nurse should plan to allow the family to visit the patient in the emergency department. Family presence may improve the condition of the patient (Emergency Nurses Association, 2000; Kelly & Newstead, 2004). The nurse should also plan to be available during the visit to ensure that the family talks to Jason in a supportive and encouraging way, and not to induce depression by blaming him.

The nurse should plan for family support. This involves talking to the family, assuring them that the patient is receiving maximum care (Leske, 1992). It may also entail listening to the family’s concerns about the patient and answering any questions that the family may have regarding the patient.

Traumatic experiences and hospitalization lead to psychological and physical pressure on the family of the patient (Goldenberg & Goldenberg, 2004; Winam & Wikblad, 2004). Jason’s case may require more care as one member of the family has died, and the other is hospitalized. The nurse should plan to provide therapy to the family to ensure that they cope with the situation at hand. The nurse should ensure that the subsystems in the family are rebuilt following interruption (Rojana, 2004).

Emergency departments are usually used for stabilization of the patient (Muntlin, Gunningberg & Calrsson, 2006). Once Jason is stable, he may be transferred to the Intensive Care Unit or to the ward. A plan should be put in place for the discharge of Jason from the emergency department to another department. There should be a plan also to prepare the patient for discharge from the emergency department by, maybe, introducing the patient and relatives to the other department that will host the patient.

Prior to the accident, Jason was involved in actions that are against the law. He was driving under the influence of alcohol; in addition, he did not have a seat belt. This led to a motor vehicle accident that killed two people. Law enforcement agencies may want to take up this matter. The nurse should plan to inform the family of the circumstances and in the case that they may want Jason to talk to a legal counsel, the nurse should provide some time for them to meet once the patient has been stabilized.

Collaborative needs

The emergency department nurse is required to work with other health professionals for effective management of Jason. Jason has limited breathing on the right side; diagnosis of pneumothorax is made. It may be necessary to insert a chest tube to relieve the pneumothorax (Smeltzer et.al, 2010). In this case, the nurse may be required to assist the physician in inserting the tube.

Bilateral tibial fracture is managed cooperatively or by casting depending on the characteristics of the fracture (Shchatzker & Tile, 2005). Closed fractures may be managed by operation or casting. Open fractures are managed by operation (Brunner & Suddarth, 2010). If the patient requires surgery, the nurse may be required to provide preoperative care to the patient. If the fractures are managed by casting, there may be a need to communicate with the relevant professional about the need for the casting. The nurse should also ensure that the patient has x-rays that may be needed before casting is done.

The patient requires nutritional support. The nutritionist and a nurse are required to work together to ensure that the Jason’s nutritional requirements are met. The nutritionist may prescribe the regimen, and the nurse ensures that the patient gets the required feeds and in the right quantities. In the case that the patient requires nasogastric tube feeding, the nurse should insert the nasogastric tube.

The patient has other needs that should be managed; he has chest pain; as a result, of blunt trauma to the sternum and he also has a pneumothorax. Medical management of the patient may require a prescription of drugs such as medication for pain and antibiotics to prevent infection. The nurse and the physician collaborate to effectively manage this patient. The physician writes a prescription, and the nurse administers the medication (Zernig, Saria, Kurz, & O’Malley, 2000).

Regarding counselling, it may be necessary to engage a counselor to talk to Jason about the traumatic experience he went through and the death of his brother and girlfriend. He may also need to be counseled on the fact that he may not be able to walk again for the next few months, as a result of the fractures.

Jason has injury to two limbs and a possibility of spinal injury. There is a likelihood that the patient may be on complete bed rest for a while. The patient may require a physiotherapist for mobilization and to improve removal of chest secretions. During chest physiotherapy, the nurse may be required to suction the patient to remove secretions. When mobilizing the patient in bed, the nurse may be required to observe to make a clear documentation of procedures performed on the patient.

Investigations such as chest x-ray, x-ray of the limbs and the spine may be ordered to confirm the various diagnoses such as tibial fracture, spinal injury and sternum injury. The radiologist will be required to perform the x- rays, but the nurse may collaborate with the radiologist by assisting in positioning the patient during the x-rays. This is vital when taking the x-ray of the spine to prevent further injury.

Conclusion:

To sum, it is evident that working in the emergency department requires critical thinking, in order to recognize, assess, plan and manage a patient as per their needs. Assessment of the patient should follow an ABCDE approach to ensure early recognition and management of life threatening conditions. The patient requires collaborative care. Nurses in the critical care department should be able to work hand in hand with all health professionals in order to give the patient holistic care. Nurses within the emergency department should be equipped with the knowledge to identify all the nursing needs of the patient. In the case of Jason, the nurse prioritized the needs using the Maslow’s hierarchy of needs, and the model of priority developed by Craven and Hirnle. Prioritizing needs aids a more holistic approach towards patient care (Iyer, 2001). The nurse also recognized the medical-legal issues surrounding the case of Jason. Holistic approach entails viewing a patient as part of the family and society. Jason’s nurse recognized the needs of the family and offered the appropriate interventions for the family. Critical thinking, teamwork, practical skills and professional knowledge are, thus, important for nurses in the emergency department.

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