Rapid Access Guide for TRIAGE AND EMERGENCY NURSES Lynn Sayre Visser, MSN, RN, PHN, CEN, CPEN, is a registered nurse with over two decades as a certified emergency nurse working in community and trauma hospitals across northern California. Her career has been complemented by experience working in prehospital care on 911 and critical care transport ambulances, ICUs, postanesthesia care units, and as an organ procurement coordinator. Her passion for quality patient care led her to play instrumental roles in the implementation of a provider in triage, rapid triage assessment, and immediate bedding processes along with formalized triage education in multiple facilities. Ms. Visser is the author of Fast Facts for the Triage Nurse: An Orientation and Care Guide in a Nutshell, which won third place in the 2015 American Journal of Nursing Book of the Year awards in the critical care/emergency category. This book has since become available in the United Kingdom under the title Essentials for the Triage Nurse: An Orientation and Care Guide. Her author team donated hundreds of copies of the award-winning book to support fund-raising efforts for nursing scholarships, which they continue to do to this day. She is a graduate of the University of California-Davis, Samuel Merritt University, Walden University, and Semester at Sea. She holds a Master of Science degree in Nursing with an emphasis in education and a double Bachelor of Science degree in exercise physiology and nursing. Anna Sivo Montejano, DNP, RN, PHN, CEN, has over three decades of experience in emergency nursing and triage education. She has taught nursing theory and aided the professional development of nurses as a preceptor, mentor, and clinical instructor. She has been a certified emergency nurse for more than 25 years. Her ED contributions include work as a staff nurse, primary preceptor, and assistant nurse manager, as well as in educational development. Dr. Montejano has worked to improve the quality and efficiency of patient care through projects such as the change process of rapid medical screenings and rapid triage assessments; as a project manager for a major ED expansion; and as an advanced cardiac life support instructor. She authored Fast Facts for the Triage Nurse: An Orientation and Care Guide in a Nutshell, which won third place in the 2015 American Journal of Nursing Book of the Year awards in the critical care/emergency category. This book has since become available in the United Kingdom under the title Essentials for the Triage Nurse: An Orientation and Care Guide. She received her doctor of nursing practice degree from California State University, Northern Consortium (Fresno and San Jose State University), her master’s degree in nursing with a focus on education from the University of Phoenix, and her BS in nursing from California State University, Fresno. Rapid Access Guide for TRIAGE AND EMERGENCY NURSES CHIEF COMPLAINTS WITH HIGH-RISK PRESENTATIONS Lynn Sayre Visser, MSN, RN, PHN, CEN, CPEN Anna Sivo Montejano, DNP, RN, PHN, CEN Copyright © 2018 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, info@ copyright.com or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Elizabeth Nieginski Compositor: diacriTech ISBN: 9780826196279 e-book ISBN: 9780826196378 18 19 20 21 22 / 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. Because medical science is continually advancing, our knowledge base continues to expand. Therefore, as new information becomes available, changes in procedures become necessary. We recommend that the reader always consult current research and specific institutional policies before performing any clinical procedure. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Contact us to receive discount rates on bulk purchases. We can also customize our books to meet your needs. For more information please contact: [email protected] Printed in the United States of America. To the front-line healthcare provider who selflessly and fearlessly cares for patients during their most vulnerable moments … and to every patient that we learned from and grew from, thank you. CONTENTS Contributors and Reviewers ix Preface x Acknowledgments xi Abbreviations xiii Share Rapid A cc ess Guide for Triage and Emergency Nurses: Chief Complaints With High Risk Presentations 1. Triage Down and Dirty ................................................1 Introduction to High-Risk Presentations....................35 2. The Secrets to Using This Guide ...............................6 8. Respiratory Emergencies .......................................39 3. Screening Tools and Checklists ...............................11 9. Cardiac Emergencies .............................................53 4. Pediatric Considerations ..........................................17 10. Neurologic Emergencies ........................................75 5. Older Adult Considerations ......................................24 11. Abdominal Emergencies ........................................94 6. Waiting Room Issues ...............................................28 12. Obstetric Emergencies ........................................121 7. Legal Issues .............................................................31 13. Gynecologic Emergencies ...................................143 vii 14. Male Reproductive Emergencies .........................153 23. Burn Emergencies ...............................................311 15. Behavioral Health Emergencies ...........................165 24. Unique Situation Emergencies.............................323 16. Toxicology Emergencies ......................................184 25. Active Shooter and/or Active Violence ................338 17. Eye Emergencies .................................................203 26. Emergency Management During a Disaster .............................................................347 18. Ear, Nose, and Throat Emergencies ....................218 References ...................................................................371 19. Musculoskeletal Emergencies .............................236 Additional Reading .......................................................373 Index .............................................................................377 20. Bite and Sting Emergencies ................................257 Rulers ...........................................................Inside Covers 21. Infectious Disease Emergencies ..........................274 22. Trauma Emergencies ...........................................289 viii Contents CONTRIBUTORS AND REVIEWERS A special thanks to these talented individuals for bringing their years of experience, knowledge, and expertise to this publication. Their critical eye in writing and evaluating content brought this book to life. CONTRIBUTORS Lori Gallian, EMT-P, BS Dawn Friedly Gray, MSN, RN, CEN, CCRN Erik Angle, RN, MICN, MEP Valerie Aarne Grossman, MALS, BSN, RN Shelley Cohen, MSN, RN, CEN Yvonne Hansen, MS, RN, CCRN Dawn Friedly Gray, MSN, RN, CEN, CCRN Laura B. Hromanik, MSN, FNP-C, RN, Major, USAF, NSC Beth Hawkes, MSN, RN-BC (Ret) Andrea Perry, MSN, RN, CNL, CEN, CPEN Deb Jeffries, MSN Ed, RN-BC, CEN, CPEN Amanda Rose, MSN, RN, CEN, TCRN, PHRN Kim Johnson, LCSW Polly Gerber Zimmermann, RN, MS, MBA, CEN, FAEN Kati Kleber, BSN, RN, CCRN Andrea Perry, MSN, RN, CNL, CEN, CPEN Lauren Schlavin Pittman, BSN, RN, CPEN, MICN REVIEWERS Amanda Rose, MSN, RN, CEN, PHRN, TCRN Daniel A. Belajic, OD, FAAO Cheri Sabella, RN, MEd, BS Shelley Cohen, MSN, RN, CEN Polly Gerber Zimmermann, RN, MS, MBA, Mary Fardanesh, BSN, RN CEN, FAEN ix