Nurse Practitioner Emergency Services CLINICAL PRACTICE GUIDELINE

Transcription

1 Scope Nurse Practitioner Wrist/forearm injury, pain, swelling or deformity Identify patients (Emergency) CPG Medical Practitioner +/-Nurse Practitioner Compound # / obvious fracture dislocation/ dislocation Neurovascular compromise Multiple injuries Altered conscious state including effects of drugs / alcohol History consistent with collapse Initial assessment and interventions History Mechanism of injuries sustained Time and Date of injury Treatment - given pre-hospital Past medical history Medications Allergies / immunisations Last food / fluids Focused clinical Look - deformity, swelling, bruising assessment Feel - bony tenderness, ligaments, tendons Move - range of movement Neurovascular assessment Snuff box tenderness, scaphoid tubercle tenderness, axial loading on thumb Colour Warmth Movement Sensation Capillary refill Peripheral pulses Identify patients not suitable for NP(Emergency) CPG and redirect Management to usual ED care with NP (Emergency) part of the ED team. Exclusion criteria identified exit CPG. Referral to EP Determine need for wrist / scaphoid /elbow x-ray. Identify patients for hand / elbow injury CPG Neurovascular compromise exit CPG. Referral to EP. Pain assessment Pain scale Determine need for and type of analgesia Analgesia/First Aid First aid - rest - ice / immobilisation - compression - elevation Reduction / relief of pain Minimise / prevent swelling Administration of analgesia (see medications) Working Diagnosis and Investigations Imaging Imaging may not be required if -Trivial injury -patient has full range of motion -no bony tenderness Wrist x-ray - include request for Scaphoid view if bony tenderness at anatomical snuff box, scaphoid tubercle or on axial loading X-ray of joint above and below injury indicated in decreased range of motion, pain, tenderness [1] Identify specific injury and determine patient management 1

2 Pathology Not routinely indicated but consider Pre operative investigations may include FBP, U&E, Group and Hold and INR as discussed with admitting medical officer. Interpretation of results (Diagnostic Features) and management decisions PAEDIATRIC CAVEATS All patients under the age of 15 presenting with injury to wrist or forearm with localised pain, require x-ray whether bony tenderness is present or not. Fracture may be present without bony tenderness. Growth Plate tenderness If no fracture/dislocation seen but open growth plate on x-ray and tenderness over growth plate, manage as fracture with immobilisation and follow up at GP or trauma clinic in 10 days for clinical reassessment + further immobilisation. No fracture seen, no bony tenderness and full function NP (Emergency) review with view to discharge patient Apply conforming tubular bandage for comfort and support High Arm Sling Patient education / health promotion follow-up appointment with GP if required Patient identified as (Emergency) CPG and discharged safely. No fracture seen but suspect fracture/ ligament injury [1] Undisplaced, non comminuted, Non intra-articular Fracture NP (Emergency) review with view to discharge patient Apply appropriate POP back slab Appointment with Orthopedic Trauma Clinic 7-10 days. Plaster check GP if appropriate High arm sling Patient education / health promotion Continuing analgesia for the patient to take following discharge from the ED until review Consider Orthopedic review if suspect instability. NP (Emergency) review with view to discharge patient Wrist: Below elbow POP backslab and High Arm sling Forearm: Above elbow POP backslab and Broad Arm sling Appointment with Orthopedic Trauma Clinic 7 days. Plaster check GP if appropriate Patient education / health promotion Continuing analgesia for the patient to take following discharge from the ED until review Patient identified as (Emergency) CPG and discharged safely with follow up in Orthopedic Trauma clinic. Patient discharged after consultation with Orthopedic Registrar Patient identified as (Emergency) CPG and discharged safely with follow up in Orthopaedic Trauma clinic. 2

3 Fracture or dislocation identified- Comminuted / Angulated / Intraarticular / Displaced NP (Emergency) review and consultation with Orthopedics Maintain Rest Ice Elevation Review and maintain analgesia Maintain Nil by Mouth consider application POP backslab if unstable or for pain management patient education / health promotion Patient referred to Orthopedic Registrar for opinion + admission Associated Care Consider ECG/CXR for patients who require surgical intervention Consider IV fluids for patients who require fasting for surgical intervention Acute Referral Referral to +/- physiotherapy +/- interpreter +/- Allied health etc When to return to ED Follow up appointments Medication instructions POP care Safety Patient discharge education ED written patient information Written instructions for GP / Orthopedic Trauma Clinic Contact ED Pharmacist to provide medication education for patient if applicable. ED written patient information Appropriate assessment of ability to perform ADL s Patients > 60 yrs of age, consider referral to Coordinated Care Team Patient understands problem, treatment, follow-up and is safe for discharge Certificates Absence from work certificates WC certificate Medications All medications will be stored, labeled and dispensed in accordance with hospital policy and relevant legislation [4] 3

4 Simple analgesia [5] S2 Mild Paracetamol 500mg: 1 or 2 tablets 4-6/24, not to exceed 8 tablets in 24 hrs. Children: Paracetamol: 15 mg/kg 4 hourly up to 4 times a day. Not to exceed 4 doses in 24 hours NSAIDS [5] S4 Moderate Narcotic Analgesia [5] S8 Severe OR add to paracetamol; Ibuprofen: 400 mg orally 6 8 hourly to maximum of 1600 mg in 24 hours (with food). Children; Ibuprofen: 10 mg/kg 3-4 times daily (over 3 months of age) Instead of Paracetamol, Panadeine Forte: 1-2 tablets 4 to 6 hourly, not to exceed 8 tablets in 24 hrs. Painstop Day: mls/kg (over 1 yr old) 4 to 6 hourly. Not to exceed 4 doses in 24 hours OR Naproxen: Adults; 500 mg initially then 250 mg 6 8 hourly to maximum 1250 mg in 24 hours (with food) If NSAIDS contraindicated, Adults and Children > 12 years Contraindicated in epilepsy, SSRI use Caution in the Elderly Maximum 300 mg daily Tramadol Oral: mg QID, maximum 400mg over 24 hours OR Tramadol Intravenous: mg QID, maximum 600mg over 24 hours ADD to Paracetamol + NSAID if still in pain Currently NPs require Medical Prescription for Schedule 8 medication Oxycodone: Adults only; Oral: 5mg every 4 hours OR Morphine Adults; Intramuscular / intravenous: 2.5mg then incremental doses to a maximum total dose of 10mg (given over period of 30 minutes) Children; IM mg / kg IV: 0.05 mg / kg given in titrated doses as guided by EP. IF PAIN NOT CONTROLLED WITH ALL 3 AGENTS, REFER TO ED CONSULTANT Patients given analgesia appropriate to allergies, current medications and past medical history. Analgesia requirements determined by ongoing assessment of pain and adequate analgesia Provided. Patients with excessive pain or pain unrelieved by analgesia need review by EP 4

5 Anti-emetic [5] PRN S4 Adults only (Contraindicated in Parkinson s Disease) Intravenous fluids Metoclopromide hydrochloride: Oral/IM/IV:10mg 8/24 Max 30 mg in 24 hours Prochlorperazine: Oral 5-10mg 8-12/24, IM deep 12.5 mg 8/24 Children: Discuss with EP 0.9% Sodium Chloride Intravenous fluid: Infusion titrated to patients requirements Children: Discuss with EP Evaluative strategies Missed fractures Emergency Department x-ray review References 1. Hoynak, B., Fracture, Wrist [emedicine] 2009 Aug 13 [cited May ]; Available from: 2. Khaldun, J & Gore, R. Fracture, Forearm. [emedicine] 2009 Mar 31 [cited May ]; Available from 3. Hunter, D., Diagnosis and management of scaphoid fractures: a literature review: Davis Hunter examines how a review of literature can help inform emergency nurses. Emergency Nurse, (7): p JHC Medication Storage and Administration Policy. Available via Hospital Intranet 5. emims 2010 [cited 2010 Dec 16]; Available via Hospital Intranet Key to terms CPG- Clinical Practice Guideline DVA- Department of Veteran Affairs EP- Emergency Physician GP General Practitioner MVIT Motor Vehicle Insurance Trust NP (Emergency)- Nurse Practitioner Emergency Services OP- Outpatients PS- Pain Score S1-S4- Schedule of the drug administration act WC- Workers Compensation Written: Sept 2006 Reviewed: Jun 2011 Review date: Jun

6 Notes for Guideline Use Statement of Intent This clinical practice guideline is intended for use by Nurse Practitioners working in the Emergency Department of Joondalup Health Campus. This clinical practice guideline is intended to serve as a guide for the Nurse Practitioner in the Management of Wrist and Forearm Injuries. Standards of care are determined on the basis of clinical data available and are subject to change as scientific knowledge and technology advance and patterns of care evolve. The parameters of practice within this clinical practice guideline should be considered a guide only. Adherence to them will not ensure a successful outcome in every case, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same result. The judgment regarding a clinical procedure or treatment plan must be made by the Nurse Practitioner in the light of clinical data presented combined with the best available evidence, diagnostic and treatment options available. In making clinical decisions the Nurse Practitioner should remain cognisant of their level of expertise and scope of practice and take advantage of the expertise of other clinicians for consultation and inclusion into the treating team to optimize patient care and discharge. This may involve direct referral and/or consultation. 6