NUR258 CH 72 EXAM NOTES GRADED A+ LATEST
UPDATE
• Ch. 72- Emergency Nursing
o Key Terms
▪ Antivenin
• Antitoxin manufactured from venom of poisonous snakes to assist
the patient’s immune system response to an envenomation
▪ Carboxyhemoglobin
• Hemoglobin that is bound to carbon monoxide and therefore is
unable to bind with oxygen, resulting in hypoxemia
▪ Corrosive poison
• Alkaline or acidic agent; causes tissue destruction after contact
▪ Cricothyroidotomy
• Surgical opening of the cricothyroid membrane to obtain an airway
that is maintained with a tracheostomy or endotracheal tube
▪ Envenomation
• Injection of a poisonous material by sting, spine, bite, or other means
▪ Fasciotomy
• Surgical incision of the extremity to the level of fascia to relieve
pressure and restore neurovascular function to the extremity
▪ Multiple trauma
• Trauma caused by a single catastrophic event that causes life-
threatening injuries to at least two distinct organs or organ
systems
▪ Primary survey
• An assessment of the patient triaged to the emergent or
resuscitation category that focuses on stabilizing life-threatening
conditions; use ABCDE (airway, breathing, circulation, disability, and
exposure)
▪ Rhabdomyolysis
• A toxic syndrome caused by widespread injury to skeletal
muscle, resulting in myoglobinuria and acute kidney injury
▪ Secondary survey
• An assessment of the patient triaged to the emergent or
resuscitation category that commences after the primary survey is
completed and
,NUR258 CH 72 EXAM NOTES GRADED A+ LATEST
UPDATE
life-threatening insults addressed; includes obtaining VS,
completing head-to-toe examination, and obtaining patient
pertinent medical- surgical history, including the history of current
event
▪ Sentinel event
• Unanticipated event that results in patient
▪ Triage
• Process of assessing patients to determine management priorities
o Learning Objectives
▪ Describe emergency care as a collaborative, holistic approach that includes
the patient, the family, and significant others
▪ Discuss priority emergency measures instituted for the patient with
an emergency condition
▪ Identify the priorities of care for the patient with multiple system injuries
▪ Compare and contrast the emergency management of patients with heat
stroke, frostbite, and hypothermia
▪ Specify the similarities and difference of the emergency management of
patients with swallowed or inhaled poisons, skin contamination and food
poisoning
▪ Explain the emergency management of patients with drug overdose, those
with acute alcohol intoxication, those who have been sexually assaulted, and
those who have been victims of human trafficking
▪ Differentiate between the emergency care of patients who are overactive,
those who are violent, those who are depressed, and those who are suicidal
o ISSUES IN EMERGENCY NURSING CARE
▪ Documentation of Consent and Privacy
• Consent to examine and treat patient
o Invasive procedures unless unconscious or in critical
condition and unable to make decision
• Document- condition, treatment, times, response to treatment,
and instructions for follow-up care
• Privacy policy- HIPAA
▪ Limiting Exposure to Health Risks
• Standard precautions
,NUR258 CH 72 EXAM NOTES GRADED A+ LATEST
UPDATE
• TB- fitted HEPA filter mask to use when treating patients with
airborne diseases
▪ Violence in the Emergency Department
• Assigned security officers or off duty police officers
• Silent alarm systems or metal detectors to identify weapons
for protection
• Safety is the first priority
• Those at risk for committing violent act- under the influence of
illicit drug or alcohol, psychiatric disorders, influenced by social
situations
• Most common type of violence is- physical accompanied by
verbal abuse
• Violent or potentially violent patients must be monitored by staff
o Avoid injury precautions
▪ Prisoners- hand or ankle restraint never released
and guard present in room
▪ Mask to prevent spitting or biting
▪ Nonrestraint- talking with patient,
minimizing environmental stimulation
▪ Physical restraints- only needed and used humanely
and professionally given
▪ Distance maintained to avoid grabbing
• Avoid wearing dangling jewelry
and stethoscopes
• Escape route
▪ Objects should not be lef t within patient reach
• IV line spike
▪ Courses on safety
• De-escalation and physical restraint techniques
o Prisoners- handcuffed to bed and assessed to ensure safety
o Safe use of restraints
▪ Providing Holistic Care
, NUR258 CH 72 EXAM NOTES GRADED A+ LATEST
UPDATE
• Patient and family experience anxiety, real and terrifying fear of
death, mutilation, immobilization and other assaults on identity and
body integrity
• Trauma- severe disfigurement, severe illness, or sudden death
o Family may experiences several stages of grief
▪ Denial, remorse and guilt, anger, grief, reconciliation
• Goal- anxiety reduction
• Close observation and preplanning of those who respond to stress
with physical violence
• Nursing diagnoses for patient
o Anxiety or death anxiety related to uncertain
potential outcomes of illness or trauma
o Ineffective coping related to acute situational crisis
• Nursing Diagnoses for family
o Grieving
o Interrupted family processes
o Compromised or disabled family coping related to
acute situational crises
• Patient-Focused Interventions
o Relieve anxiety and promote sense of security
o Human contact and reassuring words reduce panic
o Unconscious patient- should be touched, called by name,
and given explanation of every procedure performed
o Regaining consciousness- state name, date and location
o Common causes of sentinel events- staffing patterns,
patient volume, and specialty availability
▪ Solutions- optimal staffing, pharmacy presence,
and rapid diagnostics
▪ Errors should be reported and investigated with
or without harm
• Family-Focused Interventions
UPDATE
• Ch. 72- Emergency Nursing
o Key Terms
▪ Antivenin
• Antitoxin manufactured from venom of poisonous snakes to assist
the patient’s immune system response to an envenomation
▪ Carboxyhemoglobin
• Hemoglobin that is bound to carbon monoxide and therefore is
unable to bind with oxygen, resulting in hypoxemia
▪ Corrosive poison
• Alkaline or acidic agent; causes tissue destruction after contact
▪ Cricothyroidotomy
• Surgical opening of the cricothyroid membrane to obtain an airway
that is maintained with a tracheostomy or endotracheal tube
▪ Envenomation
• Injection of a poisonous material by sting, spine, bite, or other means
▪ Fasciotomy
• Surgical incision of the extremity to the level of fascia to relieve
pressure and restore neurovascular function to the extremity
▪ Multiple trauma
• Trauma caused by a single catastrophic event that causes life-
threatening injuries to at least two distinct organs or organ
systems
▪ Primary survey
• An assessment of the patient triaged to the emergent or
resuscitation category that focuses on stabilizing life-threatening
conditions; use ABCDE (airway, breathing, circulation, disability, and
exposure)
▪ Rhabdomyolysis
• A toxic syndrome caused by widespread injury to skeletal
muscle, resulting in myoglobinuria and acute kidney injury
▪ Secondary survey
• An assessment of the patient triaged to the emergent or
resuscitation category that commences after the primary survey is
completed and
,NUR258 CH 72 EXAM NOTES GRADED A+ LATEST
UPDATE
life-threatening insults addressed; includes obtaining VS,
completing head-to-toe examination, and obtaining patient
pertinent medical- surgical history, including the history of current
event
▪ Sentinel event
• Unanticipated event that results in patient
▪ Triage
• Process of assessing patients to determine management priorities
o Learning Objectives
▪ Describe emergency care as a collaborative, holistic approach that includes
the patient, the family, and significant others
▪ Discuss priority emergency measures instituted for the patient with
an emergency condition
▪ Identify the priorities of care for the patient with multiple system injuries
▪ Compare and contrast the emergency management of patients with heat
stroke, frostbite, and hypothermia
▪ Specify the similarities and difference of the emergency management of
patients with swallowed or inhaled poisons, skin contamination and food
poisoning
▪ Explain the emergency management of patients with drug overdose, those
with acute alcohol intoxication, those who have been sexually assaulted, and
those who have been victims of human trafficking
▪ Differentiate between the emergency care of patients who are overactive,
those who are violent, those who are depressed, and those who are suicidal
o ISSUES IN EMERGENCY NURSING CARE
▪ Documentation of Consent and Privacy
• Consent to examine and treat patient
o Invasive procedures unless unconscious or in critical
condition and unable to make decision
• Document- condition, treatment, times, response to treatment,
and instructions for follow-up care
• Privacy policy- HIPAA
▪ Limiting Exposure to Health Risks
• Standard precautions
,NUR258 CH 72 EXAM NOTES GRADED A+ LATEST
UPDATE
• TB- fitted HEPA filter mask to use when treating patients with
airborne diseases
▪ Violence in the Emergency Department
• Assigned security officers or off duty police officers
• Silent alarm systems or metal detectors to identify weapons
for protection
• Safety is the first priority
• Those at risk for committing violent act- under the influence of
illicit drug or alcohol, psychiatric disorders, influenced by social
situations
• Most common type of violence is- physical accompanied by
verbal abuse
• Violent or potentially violent patients must be monitored by staff
o Avoid injury precautions
▪ Prisoners- hand or ankle restraint never released
and guard present in room
▪ Mask to prevent spitting or biting
▪ Nonrestraint- talking with patient,
minimizing environmental stimulation
▪ Physical restraints- only needed and used humanely
and professionally given
▪ Distance maintained to avoid grabbing
• Avoid wearing dangling jewelry
and stethoscopes
• Escape route
▪ Objects should not be lef t within patient reach
• IV line spike
▪ Courses on safety
• De-escalation and physical restraint techniques
o Prisoners- handcuffed to bed and assessed to ensure safety
o Safe use of restraints
▪ Providing Holistic Care
, NUR258 CH 72 EXAM NOTES GRADED A+ LATEST
UPDATE
• Patient and family experience anxiety, real and terrifying fear of
death, mutilation, immobilization and other assaults on identity and
body integrity
• Trauma- severe disfigurement, severe illness, or sudden death
o Family may experiences several stages of grief
▪ Denial, remorse and guilt, anger, grief, reconciliation
• Goal- anxiety reduction
• Close observation and preplanning of those who respond to stress
with physical violence
• Nursing diagnoses for patient
o Anxiety or death anxiety related to uncertain
potential outcomes of illness or trauma
o Ineffective coping related to acute situational crisis
• Nursing Diagnoses for family
o Grieving
o Interrupted family processes
o Compromised or disabled family coping related to
acute situational crises
• Patient-Focused Interventions
o Relieve anxiety and promote sense of security
o Human contact and reassuring words reduce panic
o Unconscious patient- should be touched, called by name,
and given explanation of every procedure performed
o Regaining consciousness- state name, date and location
o Common causes of sentinel events- staffing patterns,
patient volume, and specialty availability
▪ Solutions- optimal staffing, pharmacy presence,
and rapid diagnostics
▪ Errors should be reported and investigated with
or without harm
• Family-Focused Interventions
