The Roles of Nurses in the Emergency Department, Pathophysiological Events Carried Out by Nurses in the Emergency Department - Case Study Example

Case Study By Student Name Course Tutor Institution Date CASE STUDY Ryan is 27 years old and has been involved in a car accident after swerved trying to escape hitting a goanna. His car was moving at a speed of 60km/hr. the ambulance found him an hour after the accident. Ryan has no significant health history and is neither a smoker nor on medication. Ryan had IV access and a liter of normal saline while still in the ambulance as reported by the ambulance nurses. The triage utilized indicated that Ryan’s case was urgent due to his haemothorax. The triage color was yellow, which indicated that there are high chances of Ryan’s survival if necessary care is provided in the right time. The Roles of nurses in the emergency department At this stage the nurses in the emergency department had to find out about Ryan’s medical history in order to determine the intensity and scope of their chest examination. The setting before the examination should be comfortable for both the nurse and Ryan. The nurses in the emergency department commenced their inspection, where Ryan’s body position was noted, they assessed his level of comfort, inspected and palpated his hands, as well as, noting his grip strength. Pulmonary examination has several stages namely; inspection, percussion, auscultation and palpation. Percussion confirms palpation where the assessment for degree and tenderness of chest’s expansion is examined. Auscultation is a more advanced process since it is utilized in confirming the prior findings; it set the precedence for a specified pathological process to be followed. The nurses in the emergency department made an initial assessment of Ryan’s ventilator system. Here they checked at Ryan’s rhythm, rate and breath volume. This included the effort associated with Ryan’s breathing. The normal pattern of ventilation should be effortless and regular. A deviation from this indicated that Ryan had a problem. Pathophysiological events carried out by nurses in the emergency department The nurse in the emergency department went ahead to carry out palpation. With Ryan disrobed, the nurse placed his entire palm of his hands on strategic portion of either hemithoraces followed by a gentle, but firm hand inferiorly movement up to an area below Ryan’s twelfth rib. The same process was repeated moving anteriorly and subsequent laterally; helps in searching for any deformities, tender rib areas and nodules. Once Ryan felt any discomfort, the nurse would palpate that area with increased firmness in trying to assess whether those maneuvers would reproduce Ryan’s symptoms. This palpation is extremely significant in the ventilation assessment. The nurse can utilize palpation in assessing synchrony, symmetry and each breath’s volume. In order to examine Ryan’s posterior, the nurse placed his thumbs together along the midline at tenth rib level as his hands grasped Ryan’s rib cage laterally; both tactile and visual observations were recorded during forceful inhalation and the tidal breathing volume. Palpation also helps in the examining the deviation of the tracheal. Percussion helps in the determination of whether the area beneath the percussed finger could be fluid filled (once it produces a dull sound), air filled (once the sound resonates like a drum) or solid (if the sound produced is flat). In the interpretation of the sounds, the nurses in the emergency department listened to the sound produced, as well as, the frequency and intensity of the produced vibrations (Borroso and Nogues, 2009). The final inspection done was Ryan’s chest auscultation (Ward and Wattier, 2011). The report on percussion, inspection and palpation guides the nurse of what to identify during auscultation in the identification of the precise diagnosis. The nurse utilized the stethoscope since it functions as a selective sound filter. The diaphragm helps in the auscultation of the chest since breathing produces a relatively high pitch. This examination is conducted in a quite room. The examination of Ryan’s thorax posterior was performed with Ryan’s arms interiorly crossed in order to laterally move his scapulas as much as he could. The comparison of the sides was analyzed in the identification of Ryan’s injury. Once Ryan was stabilized, the nurses in the emergency department measured his reflexes, as well as, the vital signs. His respiration rate, blood pressure, and pulse rate were checked. The Glasgow Coma Scale (GCS) was employed in the identification of Ryan’s extend of injury and his consciousness level. He was put in under CT (Computer tomography). During the examination Ryan complained of nausea. Ryan’s symptoms indicate that he could have suffered from haemothorax after the car accident. Haemothorax results from the accumulation of blood inside the pleural cavity. After Ryan’s traumatic incident, he must have had his thorax injured leading to the rapture of his serous membrane covering the lungs. The rapture led to the spillage of blood in to his pleural space. The spillage equalizes the pressure existing between it and one’s lungs. Even in minor accidents, the chest walls might experience significant hemothorax since each thorax side has the capacity of holding 30 -40% of an individual’s blood volume. The nurses in the emergency department had to first look for way to maintain Ryan’s airway with the cervical spine protection. In maintain Ryan’s airway, the nurses had to start by clearing the oropharynx of mucus, blood and existence of any foreign particles that might have entered during the accident. In doing this, the nurses lifted Ryan’s angle of the chin or jaw. This was meant to prevent Ryan’s tongue from a possible fall back resulting to airway obstruction. The neck at this point must not be overextended since the patient could be suffering from spinal injury. Use oropharyngeal tube on Ryan. The right sized oropharyngeal airway extends from the incisors to the jaw angle. Once a third of tube has been inserted, the nurses in the emergency department will rotate the tube at 180°over Ryan’s tongue (Shiber, 2012). This is the best airway management for Ryan since he does not have an intact gag reflex. During intubation, the nurses in the emergency department should apply cricoids pressure, which is meant to prevent aspiration. The application of pressure persists until the tube’s cuff becomes inflated. The right placement of the tube is indicated by the return of carbon dioxide, listening of the patient’s sound of bilateral breath and performance of chest x-rays. In cervical spine protection, the nurses in the emergence department avoid the rough manipulation of Ryan’s neck and head. This is done by utilization of hard collar meant to immobilize Ryan’s neck and the whole body using the long spinal board. Ryan does not complain of other injuries, as such, the nurses in the emergency department should employ a CT scan in the evaluation of Ryan’s cervical spine condition. Nurse’s Emergency Management plan for Ryan Breathing and Ventilation Once the existing hemothorax is not drained, the blood that has coagulated might produce a blood that is clotted, which could result into a prolonged ventilation disturbance resulting in long hospitalization (Shiber, 2012). The respiratory relief is only achievable through positive-pressure ventilation; the introduction of an airway pressure that continuous and positive, sufficient management of pain and pulmonary drainage meant to prevent the patient from contracting pneumonia. The drainage is normally supported using chest wall oscillations that possess high frequency. Ryan requires the mechanical ventilation since his hemothorax could be massive and also from the fact that he is having problems when breathing could indicate that he is experiencing impaired exchange of gases (Sherwan, Mazin and Kimball, 2012). During the diagnosis in the emergency department, it was clear that Ryan had a flail chest; he could also be having pulmonary contusion. This calls for an intervention of ventilator support. Once the ventilation support is established at the right time it can support a patient’s respiratory system preventing further lung injuries that are ventilator-associated. The noninvasive positive-pressure ventilation (NPPV) offers the patient’s with positive pressure via facial, helmet or nasal interface with the absence of endotracheal airway (Williams, Hinojosa-Kurtzberg, and Parthasarathy, 2011). This should be utilized to patients who do not possess the hemodynamic instability, aspiration risk and facial injuries. The nurses in the emergency department should first inspect the symmetrical movement of Ryan’s chest. It is during this phase the nurses identified that Ryan possessed a mild tracheal deviation toward his left hand side. The tracheal shift can either be away from or towards the problem. In Ryan case, the shift was away from the problem since he had development of blood in his lungs. Ryan has observable bruises of the seat belt sustained after the accident, he also complains of chest pains and difficulty in drawing breath. These symptoms indicate that Ryan has a flail chest. This means that, the affected portion of Ryan’s lungs is incapable of expanding. This hampers his breathing. The ultimate objective of the nurses in the emergency department is to stabilize Ryan’s chest wall, which is preceded by identification then treatment of Ryan’s injuries around his chest. Flail chest helps in suggesting the degree of internal injuries endured by a patient such as bruises and cuts on the patient’s lungs. Shortness of Ryan’s breath could have resulted from the resistance of movement from the muscles around his diaphragm and rib cage, which move expanding the chest cavity. Once there is a creation of vacuum as air gets into the lungs, the expansion is hindered (Patel et. al 2010). This condition diminishes the lung’s ability to draw air. In a flail chest, a section of the chest is isolated from the usual movement of the chest. This makes Ryan’s condition an emergency concern. In the assessment of Ryan’s case the utilization of Percussion is of utmost significance. The nurses in the emergency department utilize percussion as a main component in assessing the respiratory condition of Ryan. This process also involves auscultation, which assists in the diagnosis. The nurses in the emergency department will listen at the palpable vibrations and the percussed notes in determining whether Ryan’s underlying tissues contain fluid. This process helps in the determination of pathophysiological changes that took place in Ryan’s lungs as a result of the plural effusion. Once a patient suffers from hemothorax there is excessive bleeding into the patient’s pleural space. This results from tissues disruption on the chest’s walls. The flail chest condition experienced by Ryan prompted the nurses in the emergency department carry out a pulmonary contusion management. The flail chest and blunt thoracic trauma usually results in pulmonary contusion. Pulmonary contusion is the hemorrhage in one’s lung parenchyma caused by a damage caused by an external source. The contusion on the lungs results in the presence of interstitial fluid leading to problem in respiration (Mazhirina et al 2011). This was evident in Ryan case since his respiratory rate had significantly increased. Ryan received chest X-rays in the emergency department, which was meant to confirm the clinical signs at nurses’ disposal. Some parts of Ryan’s chest appeared white when viewed through the X-ray film. The presence of hemothorax obscured the contusion when viewed through the radiograph. Circulation and Hemorrhage control Hemorrhage is normally the cause of many accident injuries. High blood loss leads to hypovolemic shock. The nurses in the emergency unit establish two large-bore intravenous and crystalloid solutions. Once the nurses in the emergency department identify blood loss, there develops an urgency of stopping further loss. Ryan’s blood pressure had significantly dropped. The drop in blood pressure has a significance importance in the human beings since lack of enough blood pressure means that the blood tissues has inadequate oxygen and some other important nutrients, once this conditions is not rectified the patient can easily die. In order for the blood to possess the right pressure, both the heartbeat and resistance of blood flowing in the arteries must be right. At this point the blood pressure of a healthy person is 120mm/Hg, but Ryan blood pressure was recorded at 100mm/Hg. This indicated that there must have been an alteration of the normal blood pressure condition (Sherwan, Mazin and Kimball, 2012). This is normally followed by need to replace the lost volume. By doing this, the blood cells that remained after the hemorrhage are capable of oxygenating body tissues. The blood of the human beings has the capability of transporting excess oxygen, which is mostly utilized in incidences of physical exertion, as in the case of Ryan. In the case of Ryan, he can survive low levels of hemoglobin because the volume expanders are capable of maintaining blood volume. Ryan’s loss of blood is evidenced by his feeling of drowsiness. Hemothorax has an effect on the patient’s respiration response. Large blood accumulation in the pleural space might negatively affect the patient’s usual respiratory movement. In Ryan’s case, the trauma he went through during the accident led to this condition. The blood that got into Ryan’s pleural cavity was exposed to the movement of the lungs, diaphragm and many other intrathoracic structures. Once this happened, Ryan’s blood underwent incomplete clotting. After some time of cessation bleeding, there is the commencement of lysis on the existing clot. This is triggered by the pleural enzymes. This condition leads to increment of the osmotic pressure inside the pleural cavity. The increment of the osmotic pressure leads to the production of osmotic gradient, which exists between the tissues surrounding this area and pleural space favoring the fluid transudation inside the pleural space. This must have happened to Ryan after the accident since the nurses in the emergency department determined that the condition was gradually progressing into a symptomatic and big bloody pleural effusion. Once the nurses in the emergency department monitored Ryan’s CVP (central venous pressure), it was clear that Ryan’s hemothorax had affected his CVP. The central venous pressure is blood’s pressure as the blood is emptied in one’s right ventricle. The diagnosis in the emergency department indicated that Ryan’s central venous pressure had increased. A decrease in central venous pressure shows that there is reduced blood volume returning to the heart’s right side from the venous system (Sherwan, Mazin and Kimball, 2012). This could result from absolute hypovolemic state originating from hemorrhage. In an event where the clots remain in the patient’s chest, the best alternative to utilize is using the thoracoscopi video-assisted surgery (VATS), which facilitates the direct clot removal and the appropriate chest tubes placement (Fabbrucci et al. 2008). VATS is normally linked with small number of complications and also characterized by short hospital stays in comparison to thoracostomy. In the management of circulation, the nurses in the emergency department established IV line bore followed by the administration of intravenous fluid. The commonly introduced fluids are 0.4% albumin inside 0.9% blood or saline. This must be introduced early, and then this fluid is rapidly infused. The fluid choice is dependent on the level the identified blood loss. Tracheal deviation The examination in the emergency room indicated that Ryan tracheal had a mild deviation. The examination involves the placement of the nurse’s index finger on the patient’s suprasternal notch. Palpation is required in pinpointing the tracheal which is normally an uncomfortable process. This is a clinical symptom of the existence of unequal intrathoracic pressure in the Ryan’s chest cavity. Any disease or complication that results in the reduction of volume in one of the hemithorax ends up pulling the patient’s trachea to that side. In positioning of trachea, the endotracheal tube can effectively be utilized (Williams, Hinojosa-Kurtzberg, & Parthasarathy, 2011). The endotracheal’s tube tip must have a length of 5cm from roughly halfway or carina between the carina and clavicles. This is done because the tube’s tip can travel close to 2cm upward or downwards if the patient extends or flexes his neck. According to imaging findings, the carina is usually placed at the degree of T5-T7 (Karr, Rath, Prabhakar, & Ali, 2009). The tube’s width should be ½ in comparison to 2/3 of the tracheal width. Disability: Neuralogical stustus During the primary survey of Ryan’s condition, the nurses in the emergency department had to conduct the disability test. This was meant to check on Ryan’s degree of consciousness. In order to verify his status, the nurses had to employ the AVPU (alert, voice, pain and unresponsive) scale. In checking on Ryan’s alertness it was recorded that he was fully awake. Although Ryan was experiencing pain, he was not asleep by the time he was brought in the emergence department. On checking on Ryan’s voice capability, it was indicated that though he never talked much, he would respond once verbally addressed by the doctor. He could also respond using his eyes. On checking his eyes it was clear that he was still conscious. Motor aspect of Ryan had a problem since; he was unable to move his right hand and neck. On pricking his foot he would respond showing that the other parts of his body were functioning normally. He kept complaining of chest pains indicating that his response to stimuli was good. The nurses calculated Ryan’s GCS (Glasgow coma score) after the examination to 13 (Wears, 2012). Exposure/ Environment These tests are conducted in order to determine whether there are other hidden injuries. Among the injuries that were treated at this stage were the lacerations that had resulted from the pressure exerted on Ryan’s chest by the seat belt he also had other small but deep bruises that were caused by broken glasses. The crush injuries results from blunt force impact. Ryan had developed some deep cavities on the left hand caused by broken glasses. He also had areas having devitalized tissues. The nurses dressed Ryan’s wounds by debridement and cleansing of all the devitalized tissues. The dead tissues and the debris were removed, through maintaining a moist condition of the wound. The nurses also conducted a fast assessment on Ryan, which focused on four significant views. The first view was the spleno-renal, bladder, sub-xiphoid and hepato renal view. If blood is detected as the assessment progresses, this could give an indication of peritoneal penetration. Once this is detected, the patient is put on CT scanner in investigation. Hepato renal is an extremely dangerous condition since it involves quick deterioration of kidney’s functions. Once this condition arises the only remedy could be a transplant. Renal failure results from blood vessel abnormality. Once the accident or other traumatic incidences occur this should also be a priority in the primary survey. Secondary Survey The secondary survey on a patient is conducted once all the relevant primary survey has been completed and significant vital signs addressed. This survey is guided by a process referred to as the AMPLE (allergies, medication, past illness, the last meal and environment). Most patients have a tendency of having allergies one certain medication has been tried on them, as such; special care should be given to these patients. The nurses in the emergency department employ all the methods of inspection so as to verify the main injury. In doing this they perform various procedures. They utilize palpation is extremely significant in the ventilation assessment. The nurse can utilize palpation in assessing synchrony, symmetry and each breath’s volume. Percussion helps in Percussion helps in the determination of whether the area beneath the percussed finger could be fluid filled, air filled or solid. Chest auscultation is the final inspection process since it tries to analyze the records obtained from the other processes. Auscultation decides on the method that the nurses in the emergency department will adopt. It is important for one to conduct both the primary and secondary survey to eliminate any doubt, as well treating the actual injury. Proper timing of ventilation support helps the patient’s respiratory system and prevents further injury on the patient’s lungs. The noninvasive positive-pressure ventilation (NPPV) offers the patient’s with positive pressure via facial, helmet or nasal interface with the absence of endotracheal airway. Flail chest results in pulmonary contusion. Ryan had suffered from hemothorax where blood has entered into his plural space. This condition called for mechanical ventilation to prevent further damage of Ryan’s internal organs. References Borroso, F. A. and Nogues, M. A. (2009). Percussion Myotonia. New England Journal of Medicine , 360 (10), e31. Fabbrucci et al. (2008). Video-assisted thoracoscopy in the early diagnosis and management of post-traumatic pneumothorax and hemothorax. Surgical endoscopy , 22 (5), 1227-1231. Karr, P., Rath, G. P., Prabhakar, H. and Ali, Z. (2009). Tracheal deviation may be a normal anatomical variant in children. 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Wears, R. L. (2012). Lessons from the Glasgow Coma Scale. Annals of emergency medicine , 59 (4), 338. Williams, K., Hinojosa-Kurtzberg, M. and Parthasarathy, S. (2011). Control of breathing during mechanical ventilation: who is the boss? Respiratory care , 56 (2), 127. Read More