Analysis of Emergency Nursing Case - Essay Example

EMERGENCY NURSING: A CASE STUDY INTRODUCTION According to Tye (1996: 365), an “Emergency Nurse Practitioner is an accident and emergency nurse who has a sound nursing practice base in all aspects of accident and emergency nursing, with formal post-basic education in holistic assessment, physical diagnosis, in prescription of treatment and in the promotion of health”. This paper is a case study of a 22-year-old male who is brought into an emergency department by the police, as a victim of an unprovoked assault. He is observed to be suffering from head and facial injuries, multiple bruising and contusions. His homeland was a war zone, and he is a recent refugee who speaks little English. He is frightened and anxious, and because of the attack, is unable to recollect whatever English he knew. He appears suspicious of the police, and shows signs of agitation when standing near a window. Based on this case study, it is essential to identify the immediate priorities of care, how the patient would be triaged and why, provision of optimal care to the patient by services and support, and delivery of culturally appropriate care in the emergency room. DISCUSSION: Identification and Provision of Rationale for Immediate Priorities of Care, the Methods by Which the Nurse Would Triage This Patient, and the Reasons for Triaging. A failure to recognize and intervene appropriately for life-threatening conditions before progressing to the next step may result in patient deterioration states Proehl (1993: pp.12-13). The immediate priorities of care would be: assessing the airway patency, immobilizing the head if the patient is at risk for cervical spine injury, assessing breathing adequacy by observing the respiratory rate, depth and difficulty, assessing circulation by evaluating the radial or carotid pulse for rate and strength, evaluating neurological status to determine whether the patient is alert. Assessment of Facial Injuries: According to Kent & Walsh (2001: 122), the first priority in assessing the patient who has suffered facial trauma, as in all cases, is to assess the patency of the airway. Noisy, laboured breathing almost certainly indicates obstruction of the airway. The mouth should be examined for the cause of the obstruction, for example: bleeding, vomit, tongue, etc. The contours of the face should be assessed: as in a shoved-in or dish-like appearance found in Le Fort III fracture. Due to the abnormal anatomy, this would be a serious hazard to the airway. The 22-year-old patient in the case study is manifesting multiple bruises and contusions. Hence, bleeding should be assessed, and its source identified if possible since clots of blood may obstruct the airway. Cerebro-spinal fluid should be looked for, indicating a fracture at the base of the skull, if found. However, in this case, the patient is probably not suffering from a fracture, since he is able to stand near the window, and appears only frightened and anxious. The presence of a fracture would impact him much more adversely, making it impossible to stand up. Kent & Walsh (2001: 122) state that facial trauma inevitably means that the brain absorbs a substantial amount of the energy involved, leading to a possiblity of brain damage. A thorough neurological assessment with particular attention to level of consciousness is therefore required. Since the patient in the case study may have lost consciousness for a brief period, but cannot remember having done so, the neurological assessment is especially very important. If the patient is able to cooperate, the ability to oppose upper and lower sets of teeth correctly should be assessed. Failure to do so indicates a facial bone fracture. Triage is a dynamic decision-making process that prioritizes a persons need for medical care on arrival at an emergency department. The aim of an efficient triage system is to expedite time-critical treatment for patients with life-threatening conditions and ensure that all the people requiring emergency assessment are categorized according to their clinical condition (Australian Institute of Health and Welfare and the Australasian College for Emergency Medicine 2000). In this context, the triage nurses ability to take an accurate patient history, conduct a brief physical assessment, and rapidly determine clinical urgency are crucial to the provision of safe and efficient emergency care. Travers (1999: 240) states that realistic triage policies and standards were required to be developed. In the case study about the young refugee from a war zone, it is quite likely that he had been a soldier fighting in the war. That may account for his suspicion towards the police, his fright and anxiety, and for the fact that he had been agitated when standing near the window, since he may have been alert against anyone finding and arresting him. When the nurse triages the patient, she would place him in the category of patients who would be able to survive without medical treatment, as the wounds would heal on their own over a period of time. The other two categories: patients who will survive with appropriate medical interventions and those who will not survive even when treatment is administered will not be appropriate for the patient. The reason for triaging the patient in the survivors’ group is that he is not too seriously injured, and is mobile, and is not giving any cause for undue concern regarding his ability to respond to treatment. An observational study of urgency assessment needs to be the basis of the triage nurses’ clinical decision making. Gerdtz & Bucknall (2001: 550) state that researchers have described both the various decision tasks performed by triage nurses using self-report methods and identifed time as a factor influencing the quality of triage decisions. The authors undertook a research study to allocate a triage priority using the Australasian Triage Scale (ATS), to describe the duration of nurses’ decision making, and to determine the impact of patient and nurse variables on the duration of the triage nurses’ decision making in the clinical setting. A research study was conducted in an emergency department located in metropolitan Melbourne, Australia where a total of twenty-six triage nurses were observed performing 404 occassions of triage. Data was collected by a single observer using a 20-item instrument that recorded the performance frequencies of a range of decision tasks and a number of observable patient, nurse and environmental variables. Additionally, the nurse and patient interaction was recorded as time in minutes. It was found that there was limited use of objective physiological data collected by the nurses in order to decide patient acuity, and there was a large variability in the duration of triage decisions observed. In addition, analysis of variance indicated strong evidence of a true difference between triage duration and a range of nurse, patient and environmental variables, state Gerdtz & Bucknall (2001: 550-551). The findings have implications for practice standards: that they should include routine measurement of physiological parameters in all but the collapsed or obviously unwell patient where time-critical intervention should not be delayed. Furthermore, the inclusion of arbitrary time frames for triage assessment in practice standards are not an appropriate method of evaluating triage decision making in the real world. A Rationale for Services and Support that Need to be Involved in Order to Provide Optimal Care to the Patient: For the case study patient , 22-year-old male refugee brought to the emergency department with serious injuries in the head and face, bruises and contusions, probable loss of consciousness for a short duration; and in a mental state of fear and anxiety, the most effective services and support staff need to be called. The emergency nurse would need to give first aid to the patient after assessing the type of wounds that he has sustained. Besides cleaning and dressing the wounds, the contusions and bruises would need to be treated with internal medication as well as local application of a soothing antibacterial ointment. In order to address the more serious concerns of possible internal head injury and the loss of consciousness, the emergency care nurse would need to get a scan done of the patient’s head, and neurological tests for ascertaining the condition of the patient’s nervous system. The reports and results of the scan and tests she would need to show to specialist medical practitioners like a neurosurgeon, to get his advice and plan of treatment of the patient. Another senior critical care nurse would be required to help in calming the patient and to talk to him. The patient’s responses to their questions are crucial. Since the refugee cannot converse in English. The services and support group that need to be on call at a moment’s notice, in order to help a critically ill accident victims is mainly the medical emergency team. When clinically unstable patients require help suddenly, the life-saving interventions immediately given by the emergency team generally comprising of doctors and a senior critical care nurse, aid in overcoming the crisis (Buist, et al, 2002: 387). According to Kerridge and Saul (2003: 313), the medical emergency team (MET), which may be summoned by anyone in a hospital to treat a patient who appears acutely unwell, has been generally accepted as scientifically rational, with no adverse clinical outcomes and only modest resource requirements. Despite this, many centres appear to be awaiting a universal standard of evidence of its effectiveness. The authors suggest that the quest for evidence is providing scientific justification for institutional inertia, and that further delay in implementing this system may even be unethical. They propose that decisions about changes in healthcare should consider scientific rationality, clinical reasonableness and resource implications, as well as evidence and ethical implications. According to Cioffi (2000: 108), patient survival often depends on decisions by nurses to call emergency assistance. The author conducted a descriptive study to explore the experiences of registered nurses, using 32 nurses from whom responses were collected using unstructured interviews. The main findings were that nurses questioned whether they were doing the “right thing” calling the emergency team, sometimes collaborated with others prior to calling and most felt nervous and anxious. They recognized patient deterioration from feelings they had that something was wrong. However, they were not able specify exactly what the change was. Knowing the patient and past experiences were involved in the recognition of deterioration. This association indicates the importance of experience in the development of clinical decision-making skills. Further, nurses calling emergency assistance need to be provided with the opportunity to debrief after calling. It is essential that nurses do not devalue or ignore concerns they may have about patients. Since 1990 a unique initiative, the Medical Emergency Team (MET) has been operating in an Area Health Service in Sydney, Australia. The MET has superseded the existing cardiac arrest team and provides two levels of intervention: resuscitation for life-threatening emergencies, and assessment and review for all calls that are not classified as immediately life threatening (Lee et al. 1995: 183). The aim of the MET is to promote early intervention to prevent the occurrence of cardiac arrest and its associated morbidity and mortality (Daffurn et al. 1994: 115). The MET is modelled on the principles of early recognition and rapid response used to manage severe trauma. To assist clinicians to recognize patient information pertinent for calling the MET, criteria of clinical antecedents associated with clinical deterioration are specified. These include abnormal physiological variables, abnormal laboratory results, specific conditions and any time medical or nursing staff are “worried by a patients condition” (Daffurn et al. 1994: 115). Nurses use the criteria to call the MET markedly more than other health professionals. This may be due to the fact that they have more consistent direct contact with patients and therefore are in a stronger position to detect changes in their conditions than other health workers. Nurses have been shown to discern patients `at risk and have claimed their decision making to be intuitive-experiential. For example, a nurse who called the emergency code for a patient assessed as “going sour” just before he had a respiratory arrest stated she had been suddenly sure that he was going to have an arrest (Benner & Tanner 1987: 23). Another nurse recalled havin “bad feelings” about a patient whose observations had not changed much but who was becoming restless and vaguely complaining of not feeling good. She called the medical officer and by the time he arrived the patient was having copious burgundy liquid stools indicative of a massive haemorrhage (Benner & Wrubel 1982: 11). Nurses often recall experiences where patient survival has depended on skilful decision making. These decision-making situations require nurses to recognize early signs of clinical deterioration in patients. Some decision-making situations have been identified to be more complex than others, involving more unknowns and uncertainties. Services and support team being available in the medical care facility or hospital is a positively reassuring feature for the patients as well as the nursing staff. It is a vital necessity as a standby for consultation and advise on best possible action that can give best results in patient outcome. The Impact of the Refugee’s Lack of English, and Recent Traumatic Past With Respect to Delivery of Culturally Appropriate Care in the Emergency Room: The patient appears to have lost his limited knowledge of English due to the trauma he has suffered, hence the task of getting personal details about him becomes more difficult for the nursing staff at the emergency department. It is part of professional ethics that the patient should receive care that is culturally appropriate, that he can understand. For this purpose, it is essential that the services of an interpreter are engaged, so that the patient as well as the health care professionals can communicate thoroughly, for best results. If the new immigrant has any friends who can be contacted, they should be sent for, to put him at ease in familiar company. In a more relaxed frame of mind, the patient would be able to cooperate better to the medical interventions which are aimed at helping him to heal earlier. Delivery of culturally appropriate care in the emergency room is an essential part of emergency department functioning. The challenge for emergency nurses today is to meet the needs of a culturally diverse patient population with ever-shrinking emergency department resources. When cultural barriers are not addressed, difficulties communicating with members of minority groups can exacerbate presenting symptomatology, lead to unnecessary diagnostic and treatment procedures, and significantly increase costs. Negotiating culturally competent care is advised by some researchers. However, when emergency nurses use cultural care concepts, the number of barriers encountered is reduced, advocacy is enhanced, and care is ultimately improved, state Bechtel & Davidhizar (1999: 377). Communication: One of the most difficult aspects of facilitating the communication process is overcoming ethnocentrism, or viewing one’s own culture as superior to that of others, particularly when communicating issues of pain and psychological distress, state Bechtel & Davidhizar (1999: 377). People from some cultures may verbally agree with a treatment plan out of respect to the provider but then defer to folk remedies or alternative health practices upon discharge. Space: Views of appropriate spatial distance vary between persons of different cultures. Giger and Davidhizar identified four aspects of behavior patterns that must be assessed to promote a healthy interaction: (1) proximity to others, (2) attachment with objects in the environment, (3) body posture, and (4) movement in the emergency setting. These 4 concepts are particularly important during periods when family members are experiencing emotional chaos, such as during the grieving process. Although the desired degree of physical proximity between the client and provider is based on the degree of intimacy and trust mutually established, as a general rule, Hispanics and Asians tend to stand closer to each other than do Euro-Americans. Emergency department nurses should also be aware that members of many cultures are very concerned with modesty and often prefer that health providers of the same sex should perform examination of the patient. Thus the emergency department nurse should always be cognizant that cultural values and beliefs may significantly affect responses and misinterpretations in communications, and can lead to diminished health outcomes (Bechtel & Davidhizar, 1999: 377). Social organization: The need for social congruency with one’s cultural group may have an adverse impact on essential care. Access to health providers does not necessarily translate into positive lifestyle behaviors or risk-reduction activities as prescribed by the dominant society. People from some cultures may verbally agree with a treatment plan out of respect to the provider but then defer to folk remedies or alternative health practices upon discharge (Bechtel & Davidhizar, 1999: 378). Role perceptions based on gender, age, and religion are all culturally based and significantly influence how individuals perceive their illness and who is ultimately responsible for follow-up home care. Time: The concept of time is not only based on clock hours and social influences (eg, meals and holidays) but is perceived differently by persons in various cultures, state (Bechtel & Davidhizar, 1999: 378). Clock time is frequently more highly valued by the majority of Western cultures, where appointments tend to be kept at the prescribed time. In a culture in which places and persons are more important than social time, activities start when a previous social event has been completed, and to be dominated by adherence to clock time is often considered rude. Delivery of Culturally Appropriate Care in the Emergency Room The Giger and Davidhizar Transcultural Assessment Model provides a framework to systematically assess the role of culture on health and illness and has been used extensively in a variety of settings and by diverse disciplines. This model does not presuppose that every person within an ethnic or cultural group will act or behave in a similar manner. In fact, Giger and Davidhizar emphasize that a culturally appropriate model must recognize differences in groups while avoiding stereotypical approaches to client care. In addition, the 6 cultural phenomena described are not mutually exclusive but are related and often interact. Whereas the phenomena vary with application across cultural groups, the concepts of the model are evident in every cultural group. CONCLUSION: The case study of the patient in the emergency care department is an example of the emergency care given to a youth belonging to a different culture, who is brought to the facility in a poor physical and mental condition as a result of unprovoked assault. Emergency nursing care is initiated by first prioritizing medical interventions with the purpose of saving the life, and then services and support are brought in to provide optimal care to the patient. Finally, the cultural aspect is taken care of, so that the new immigrant gets the required treatment, and best patient outcome can be achieved. REFERENCES Australasian College for Emergency Medicine 2000. Web site: http://www.acem.org.au/media/policies_and_guidelines/P06_Aust_Triage_Scale_-_Nov_2000.pdf Retrieved on 16 June, 2007. Australian Institute of Health and Welfare. Web site: http://www.acem.org.au/media/policies_and_guidelines/P06_Aust_Triage_Scale_-_Nov_2000.pdf Retrieved on 16 June, 2007. Bechtel, Gregory & Davidhizar, Ruth (1999). “A Cultural Assessment Model for Emergency Department Patients”. Journal of Emergency Nursing, 1999, Vol.25: pp.377-380. Benner P. & Tanner C.A. (1987). “Clinical Judgement: How Expert Nurses Use Intuition”. American Journal of Nursing 87: pp.23-43. Benner P. & Wrubel J. (1982) “Skilled Cinical Knowledge: the Value of Perceptual Awareness”. Nurse Educator 6: pp.11-17. 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