Emergency Nurse Procedures



DESCRIPTION

This is the process of building a therapeutic relationship/environment with the patient/client and family who visit the hospital. It makes the patient/client and family feel at ease to discuss his/her needs with the nurse. This action is performed by the nurse immediately he/she comes into contact with a patient/client and family

AIMS

  1. Develop mutual trust between patient/client and the nurse
  2. Reduce anxiety
  3. Maintain the dignity of patient/client
  4. Promote effective communication

TYPES

  1. N/A

DESCRIPTION

It is the act of describing a procedure, an action or task that will be carried out for a patient/client and or the family during the delivery of care.

AIMS

  1. Seek patient/client and family’s co-operation and consent
  2. Provide clear understanding of the action or task
  3. Allay fear and anxiety
  4. Indicate the purpose of the procedure
  5. Aid in patient/client and family’s compliance to treatment

TYPES

  1. N/A

DESCRIPTION

Cardiopulmonary Resuscitation (CPR) is a fundamental life support technique aimed at providing oxygen to the brain and the heart until appropriate definitive medical treatment can reinstate regular heart ventilatory function.

AIMS

  1. Maintain vital blood flow
  2. Ensure continuous oxygenation to the brain
  3. Sustain adequate oxygen supply to the heart
  4. Preserve life until definitive medical treatment
  5. Support life by means of haemodynamics, through chain of activities
  6. Prevent irreversible cerebral damage from anoxia
  7. Continue observation of patient and document findings
  8. Restore cardiopulmonary function

TYPES

  1. N/A

DESCRIPTION

Cardiopulmonary Resuscitation (CPR) is a fundamental life support technique aimed at providing oxygen to the brain and the heart until appropriate definitive medical treatment can reinstate regular heart ventilatory function.

AIMS

  1. Maintain an open and clear airway
  2. Maintain vital blood flow
  3. Ensure continuous oxygenation to the brain
  4. Sustain adequate oxygen supply to the heart
  5. Preserve life until definitive medical treatment
  6. Support life by means of haemodynamics, through chain of activities
  7. Prevent irreversible cerebral damage from anoxia
  8. Save the life of the patient
  9. Restore cardiopulmonary function

TYPES

  1. N/A

DESCRIPTION

A series of life-saving interventions performed after unsuccessful Basic Life Support. This may involve invasive procedures such as intubation, IV medication administration (epinephrine) and ends with post cardiac arrest care.

AIMS

  1. Optimize patient/client’s chances of survival
  2. Restore cardiopulmonary function
  3. Prevent severe vital organ damage
  4. Identify and treat reversible causes of cardiac arrest

TYPES

  1. N/A

DESCRIPTION

This is a process of obtaining an arterial blood sample to evaluate the function of the respiratory system and the acid-base balance in the blood.

AIMS

  1. Determine the adequacy of oxygenation and ventilation
  2. Assess acid-base balance
  3. Monitor the effectiveness of treatment
  4. Diagnose respiratory, renal and metabolic disorders

TYPES

  1. N/A

DESCRIPTION

The process of conducting preliminary assessment, sorting out of client/patient based on the severity of their conditions and urgency of treatment using the South African Triage Scale (SATS).

AIMS

  1. To expedite the delivery of time for treating critical patients with life threatening conditions
  2. Ensure that all patients are appropriately categorized according to their medical urgency
  3. Improve patient flow

TYPES

  1. N/A

DESCRIPTION

A process that involves clinical judgement based on assessment of the type, significance and context of the individual’s pain experience.

AIMS

  1. Identify the underlying cause of pain
  2. Determine severity of pain
  3. Evaluate impact of pain on patient quality of life
  4. Evaluate the effectiveness of interventions and relieving measures

TYPES

  1. N/A

DESCRIPTION

It is a non-invasive procedure performed to monitor the electrical activity of the heart over a period of time.

AIMS

  1. Assess patient before, during and after administering of certain medications
  2. Assess heart rate and rhythm for any abnormalities
  3. Identify abnormal heart rate or rhythms which can be used to diagnose and treat various heart conditions

TYPES

  1. N/A

DESCRIPTION

This is the act of recording electrical signals from the heart during myocardial contraction and relaxation by the use of electrodes and 12-Leads on the skin to detect the heart's electrical activity.

AIMS

  1. Detect structural abnormalities
  2. Identify irregularity in the heart rhythm
  3. Identify inadequate blood flow to the heart
  4. Detect damage to the heart muscles e.g. myocardial infarction
  5. Monitor the health of patients/clients diagnosed with heart problems

TYPES

  1. Resting ECG
  2. Stress or exercise ECG
  3. Ambulatory ECG (Holter monitors)

DESCRIPTION

This is the administration of therapeutic electrical energy to the heart through the chest walls over a brief period to revert to a normal heart rhythm.

AIMS

  1. Provide immediate intervention for patients experiencing sudden cardiac arrest or life threatening arrhythmias
  2. Restore the heart’s normal electrical activity by delivering a controlled electrical shock
  3. Improve the chances of individuals experiencing cardiac emergencies

TYPES

  1. N/A

DESCRIPTION

The process of administering IV medication at a predetermined rate and duration using a syringe pump when a precise control over the medication dosage is required.

AIMS

  1. Deliver medication in precise and controlled amounts
  2. Minimize the risk of medication errors and adverse reactions
  3. Provide a reliable delivery system to enable a continuous and controlled administration of medication and fluids over an extended period
  4. Administer medications intermittently or continuously

TYPES

  1. N/A

DESCRIPTION

This is a clinical evaluation of a client/patient’s level of consciousness that reflects activities of higher brain centres. It assesses patient’s best eye opening, verbal and motor responses.

AIMS

  1. Determine the presence of brain dysfunction
  2. Records the consciousness state of a patient
  3. Grade the severity of impaired consciousness in patients
  4. Monitor for improvement or deterioration of patient’s level of consciousness (LOC)

TYPES

  1. N/A

DESCRIPTION

This is a procedure which involves the process of securing and mobilizing the affected bone(s) or joint(s) to prevent further movement and it is typically done using various medical devices and techniques.

AIMS

  1. Minimize pain and discomfort
  2. Prevent further injury
  3. Facilitate proper healing
  4. Reduce the risk of complications
  5. Aid in transport and handling

TYPES

  1. N/A

DESCRIPTION

This is an application of a cervical collar to the cervical spine to maintain immobilization and stabilization of the cervical spine in cases of suspected neck injury or trauma.

AIMS

  1. Maintain a neutral alignment of the cervical spine
  2. Prevent further injury
  3. Minimize lateral movement of the whole body in relation to the neck

TYPES

  1. N/A

DESCRIPTION

This is the setting of a trolley for a medical procedure where an intravenous catheter is inserted into a large vein (subclavian, internal jugular or femoral) when multiple medications need to be administered quickly.

AIMS

  1. 1. Facilitate the insertion of venous catheter
  2. 2. Administer medications

TYPES

N/A

DESCRIPTION

This is a rapid first-aid procedure in which an abrupt force is used to dislodge a foreign body from the upper airway tract to restore normal breathing.

AIMS

  1. Relieve choking in adult patient
  2. Establish immediate functional airway

TYPES

  1. N/A

DESCRIPTION

This is a quick assessment to identify life-threatening injuries and prioritize care.

AIMS

  1. Rapid identification of life threatening injuries
  2. Prioritize care
  3. Minimize delay in treatment
  4. Establish baseline vital signs
  5. Assess airway, breathing and circulation (ABC)

TYPES

  1. N/A

DESCRIPTION

This involves a comprehensive and specialized approach to provide life-sustaining respiratory support. This process encompasses a series of crucial steps and considerations.

AIMS

  1. Maintain adequate oxygenation and ventilation
  2. Prevent hypoxemia and hypercapnia
  3. Protect lung tissue
  4. Optimize respiratory mechanics
  5. Promote patient comfort and synchrony
  6. Prevent ventilator associated complications
  7. Minimize work of breathing

TYPES

  1. N/A

DESCRIPTION

Nebulization is a method of delivering medication directly to the patient’s airways, in the form of a mist or aerosol.

AIMS

  1. Assess the patient’s airway, breathing and circulation and prioritize care based on the severity of the condition and any underlying respiratory conditions
  2. Determine the underlying cause of a respiratory distress, such as asthma, bronchitis, pneumonia or an exacerbation of a chronic obstructive pulmonary disease
  3. Administer supplemental oxygen to maintain adequate oxygenation
  4. Administer the nebulized medication via a mask, mouthpiece or endotracheal tube, depending on the patient’s condition

TYPES

  1. N/A

DESCRIPTION

This is a basic emergency technique used to deliver oxygen to a patient not breathing normally until a more definitive airway is established. This procedure can be done in isolation or along with chest compression during CPR in the pre-hospital and hospital settings.

AIMS

  1. Facilitate oxygenation and ventilation of patients
  2. Resuscitation of patients

TYPES

  1. N/A

DESCRIPTION

It is the process of administering medication through a catheter into centrally located veins in critically ill patient.

AIMS

  1. Administer intravenous medications that may harm smaller peripheral veins
  2. Serve as preferred route in patients requiring prolonged intravenous therapy
  3. Administer fluids or blood products for large volume resuscitation

TYPES

  1. N/A

DESCRIPTION

Delivering medication into a large vein using a central line with absolute precaution. Care is taken to adhere to aseptic technique and vigilant monitoring of the patient.

AIMS

  1. Rapid and efficient delivery of medications directly into the bloodstream
  2. Deliver medications that are highly irritating to peripheral veins
  3. Properly maintained central lines can have a lower risk of infection compared to peripheral IVs

TYPES

  1. N/A

DESCRIPTION

This outlines the systematic daily care of the central venous catheter by the nurse. It involves assessment and sterile dressing of the catheter. The catheter insertion site is observed at least 3 times per day.

AIMS

  1. Prevent catheter based skin site and related blood stream infection, central line thrombosis and mechanical complications

TYPES

  1. N/A

DESCRIPTION

This is a procedure followed to prepare adequately for inserting a chest tube through the chest wall and into the pleural cavity, allowing for drainage and re-expansion of the lung.

AIMS

  1. Ensure patient safety and prevent introduction of infection

TYPES

  1. N/A

DESCRIPTION

It is a procedure which involves the change of dressing at a chest tube insertion site.

AIMS

  1. Facilitate wound healing
  2. Prevent wound site infection
  3. Promote body comfort

TYPES

  1. N/A

DESCRIPTION

This involves the insertion of a rigid plastic shaped tube according to the outline of the hard and soft palate as well as the tongue into the mouth. This helps to create and maintain airway patency in an unconscious patient or minimal responsive patient who is not breathing spontaneously.

AIMS

  1. Prevent the tongue from blocking the airway
  2. Aid in ventilation during a code
  3. Facilitate suctioning in patients with altered level of consciousness

TYPES

  1. N/A

DESCRIPTION

The act of inserting a soft rubberlike tube with a bevelled tip inserted into the nasal cavity. This is to help create and maintain upper airway patency in an unconscious patient or minimal responsive patient who is not breathing spontaneously.

AIMS

  1. Aid in ventilation during a code
  2. Facilitate suctioning in patients with altered level of consciousness
  3. Protect and maintain a patent airway

TYPES

  1. N/A

DESCRIPTION

This is a procedure where a BVM is used to deliver oxygen to a patient with respiratory failure or difficulty breathing; by the rescuer squeezing to deliver an inflow oxygen into the patient’s lungs but preventing exhaled air from entering the bag.

AIMS

  1. Assist with the removal of CO₂ from the blood
  2. Maintain oxygenation above 94%
  3. Provide support during airway management
  4. Sustain respiratory function until definitive measure can be taken

TYPES

  1. N/A

DESCRIPTION

This is a procedure of stabilizing and immobilizing the pelvis of a patient suspected of having pelvic fracture or instability with the use of a pelvic binder.

AIMS

  1. For pelvic stability
  2. Control haemorrhage
  3. Relieve pain and promote comfort
  4. Minimize secondary injury
  5. Facilitate safe patient transport

TYPES

  1. N/A

DESCRIPTION

Endotracheal intubation is a medical procedure in which a tube is inserted through the mouth or nose into the trachea to establish and secure a patent airway.

AIMS

  1. Facilitate mechanical ventilation
  2. Protect the airway from aspiration
  3. Ensure the delivery of adequate oxygen and anaesthetic gases directly into the lungs

TYPES

  1. N/A

DESCRIPTION

It is the medical intervention aimed at clearing the respiratory passages of any obstructive objects or substances that may compromise airflow.

AIMS

  1. Ensure the patency of the airway allowing for unobstructed breathing and ventilation
  2. Prevent aspiration
  3. Promote adequate oxygenation of the lungs to prevent hypoxia

TYPES

  1. N/A