Emergency Nursing

Chapter 71
Emergency Nursing
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Objectives
At the end of this session the student
should be able to:
1.Define the terms: emergency nurse and
triage;
2.Explain the process of triaging;
3.Identify the priority disorders in triaging;
and
4.Discuss how patients are managed
presenting with emergency disorders.
Scope and Practice of

Emergency Nursing
Emergency management traditionally
refers to urgent and critical care needs.
The ED has increasingly been used for
non-urgent problems
Emergency management has broadened
to include the concept that an
emergency is whatever the patient or
family considers it to be.
The emergency room staff works as a
team.
The Emergency Nurse

The emergency nurse has had specialized
education, training, experience, and
expertise in assessing and identifying
patients health care problems in crisis
situations.
Nursing interventions are accomplished
interdependently in consultation or under
the direction of a physician or nurse
practitioner.
Priority Emergency Measures for

all Patients
Safety is the first priority
Preplanning to assure security and a safe
environment
Close observation of patient and family members
in event that they respond to stress with physical
violence
Assessment of patient and family psychological
function
Patient and family focused interventions
Actions to relieve anxiety and provide a sense of security

Allow family to stay with patient, if possible, to alleviate anxiety
Provide explanations and information
Additional interventions are provided depending upon the stage of crisis
Triage
Triage
sorts patients
based on the severity of health problems
Takes in account the immediacy with which
these problems must be treated
The triage nurse collects data and classifies

the illnesses and injuries to ensure that the
patients most in need of care do not
needlessly wait.
Protocols may be initiated in the triage area.
Triage Categories
Three levels
Emergent
Highest priority
Life threatening conditions
Must be seen immediately
Urgent
Serious problems
Not immediately life threatening
Triaging Contd.
Nonurgent
Episodic illnesses
Address within 24hrs,
fast track
Simple first aid/primary care
Can be referred
Triage
Five level system
Resuscitation
Emergent
Urgent
Nonurgent
Minor
Triaging Contd.
The obvious first-priority patients are those
with multiple trauma:
Gunshot or stab wounds

Persons involved in motor vehicle accidents
Persons with obvious CVA
Persons with severe chest pain/heart attack
Patients in shock or who have unstable vital
signs
Persons presenting with respiratory

symptoms
Principles of Emergency Care

Assess and Intervene
A, B, C
Neuro
Health history
Head-to-toe assessment
Principles of Emergency Care

(contd)
Diagnostic and lab testing
Insertion of monitoring devices
Splinting
Wounds
Airway Obstruction
Head-Tilt-Chin-Lift Maneuver
Jaw-Thrust Maneuver
Oropharyngeal Airway Insertion
Endotracheal Intubation
Alternative Intubation Method
Cricothyroidotomy
EFGHI =
E- Expose the patient
F- *Full set of vital signs, *five
interventions (cardiac monitor, pulse
oximetry, urinary catheter, NG if not
contraindicated, lab studies)
G- giving comfort measurespain control,
reassurance to patient and family
H- history/ head to toe assessment
I- inspect for hidden injuries-log roll patient
to inspect posterior aspect.
Trauma
An unintentional or intentional wound or injury
inflicted on the body from a mechanism
against which the body cannot protect itself
Collection of forensic evidence
A critical role of the nurse!
Documentation may be used in legal proceedings
If criminal activity suspected, bag clothes and
belongings and give to law enforcement; document
the name of officer
If suicide or homicide, must notify medical
examiner
Multiple trauma
Priority management
15
Wounds
Restore physical integrity and function of injured
tissue, with minimal scarring and without infection
Wound cleansing
Primary closure
Delayed primary closure
Management of Patients with

Intra-Abdominal Injuries
Blunt trauma or penetrating injuries
Abdominal trauma can cause massive life-threatening
blood loss into abdominal cavity
Assessment
Obtain history
Abdominal assessment and assess other body
systems for injuries that frequently accompany
abdominal injuries
Assess for referred pain which may indicate spleen,
liver, or intraperitoneal injury
Laboratory studies, CT scan, abdominal ultrasound
(FAST), diagnostic peritoneal lavage
Stab woundsinography

Intra-Abdominal Injuries
Assure airway, breathing, and circulation

Immobilize cervical spine
Continually monitor the patient
Document all wounds
If viscera are protruding cover with sterile, moist
saline dressing
Hold oral fluids
NG to aspirate stomach contents
Tetanus and antibiotic prophylaxis
Rapid transport
surgery
indicated
Copyright to
2010 Wolters
Kluwer Health |if
Lippincott
Williams & Wilkins
Priorities of Care for the Patient

with Multiple Trauma
Requires a team approach
Determine extent of injuries and
establish priorities of treatment
Assume cervical spine injury
Injuries interfering with vital
physiologic function have highest
priority
Priorities in the Management of

the Patient With Multiple Injuries
Priorities in the Management of

the Patient with Multiple Injuries
(cont.)
Hemorrhage
Fluid Replacement
Control of External Hemorrhage
Control of Internal Bleeding
Hemorrhage
Management
Fluid replacement
Blood, crystalloids, colloids
If large volume rapid infusion, need to warm fluids to
prevent hypothermia
Control of internal hemorrhage, usually via

emergent surgery; administer PRBCs while
awaiting surgery
Control of External
Hemorrhage
Direct Pressure
Elevation
Compression of pressure points
(arteries, veins)
AVOID tourniquetscan compromise
loss of circulation and loss of limb
Environmental Emergencies:
Hypothermia
Internal core temperature is 35C or less

Elderly, infants, persons with concurrent
illness, the homeless, and trauma victims
are at risk
Alcohol ingestion increases susceptibility
Hypothermia may be seen with frost bite and
treatment of hypothermia takes precedence
Physiologic changes in all organ systems
Monitor continuously

Hypothermia
Use ABCs, remove wet clothing, and

rewarm
Rewarming
Active core rewarming
Cardiopulmonary bypass, warm fluid administration,

warm humidified oxygen, warm peritoneal lavage
Passive external rewarming
Warm blankets and over the bed heaters
Note: Cold blood returning from the

extremities has high levels of lactic acid
and can cause potential cardiac
dysrhythmias and electrolyte disturbances

Poisoning
Poison is any substance that when ingested,

inhaled, absorbed, applied to the skin, or
produced within the body in relativity small
amounts injures the body by its chemical
action.
Treatment goals:
Remove or inactivate the poison before it is
absorbed
Provide supportive care in maintaining vital
organs systems
Administer specific antidotes
Implement treatment to hasten the elimination of
the poison

Ingested PoisonsAssessment
ABCs
Monitor VS, LOC, ECG, UO
Laboratory specimens
Determine what, when, and how much
substance was ingested
Signs and symptoms of poisoning and
tissue damage
Health history
Age and weight

Ingested Poisons
Measures to remove the toxin or decrease its
absorption
Use of emetics
Gastric lavage
Activated charcoal
Cathartic when appropriate (sod. Sulphate,
mag. Sul)
Administration of specific antagonist as
early as possible
Poision Ingestion: Contd.

Other measures may include
diuresis, dialysis or hemoperfusion
Corrosive agents such as acids and
alkalines cause destruction of tissues by
contact. Do not induce vomiting with
corrosive agents.
Management Patients with

Carbon Monoxide Poisoning
Inhaled carbon monoxide binds to hemoglobin as
carboxyhemoglobin.
ManifestationsCNS symptoms predominate
Skin color is not a reliable sign and pulse
oximetry is not valid
Treatment
Get to fresh air immediately
CPR as necessary
Administer oxygen; 100% or oxygen under
hyperbaric pressure
Monitor continuously

Food Poisoning
A sudden illness due to the ingestion of
contaminated food or drink
ABCs and supportive measures
Note: Food poisoning, such as botulism or
fish poisoning, may result in respiratory
paralysis and death
Determination of food poisoning
Treat fluid and electrolyte imbalances
Control nausea and vomiting
Clear liquid diet and progression of diet
after nausea and vomiting subside

Substance Abuse
Acute alcohol intoxicationa
multisystem toxin
Alcohol poisoning may result in death
Maintain airway and observe for CNS depression
and hypotension
Rule out other potential causes of the behaviors
before it is assumed the patient is intoxicated
Use nonjudgmental, calm manner
May need sedation if noisy or belligerent
Examine for withdrawal delirium, injuries, and
evidence of other disorders
Crisis Intervention: Rape Victims

How the patient is received and treated in the ED is
important to his or her psychological well-being.
Crisis intervention begins as soon as the patient enters
the facility; the patient should be seen immediately
Goals are to provide support, reduce emotional
trauma, and gather evidence for possible legal
proceedings
Patient reaction; Rape trauma syndrome
History taking and documentation
Physical examination and collection of forensic
evidence
Role of the sexual assault nurse examiner
Psychiatric Emergencies
Overactive patients, violent behavior,
underactive or depressed patients and suicidal
patients
Management
Maintain the safety all persons and gain control of
the situation
Determine if the patient is at risk for injuring
himself or herself or others.
Maintain the persons self-esteem while providing
care
Determine if the person has a psychiatric history or
is currently under care to contact that therapist
Crisis intervention
Interventions specific to each of the conditions
Family Violence, Abuse and

Neglect
Clinical manifestations
Physical injuries
Multiple injuries or injuries that are not well explained
Common injuries include bruises, lacerations,
fractures, head injuries
Psychological manifestations
Anxiety, insomnia, vague GI complaints
Usually do not identify abuser

Neglect may manifest as poor hygiene,
dehydration, inattention to known medical needs
36

Neglect
Assessment
Acute awareness for signs of possible abuse/neglect

Question patient in private, away from possible
abuser
Careful documentation
May include quotations and photographs - may be
used in legal proceedings
Management
If abuse or neglect is suspected, primary concern is
for the safety of patient
Multidisciplinary
MD, RN, social worker, authorities
37

Neglect
Mandatory reporting laws
If child or elder abuse is SUSPECTED,

health care workers must report suspicion
to Child or Adult Protective Services
Proof is not required
If report made in good faith, no criminal or
civil liability against HCW
38
Emergency Operations Plan

(EOP)
Health care facilities are required to
create a plan for emergency preparedness

and to practice this plan twice a year.
Essential components of the plan:
An activation response
An internal/external communication plan
A plan for coordinated patient care
Security plans
Identification of external resources
A plan for people management and traffic
flow
Emergency Operations Plan

(EOP)
Essential components of the plan:

A data management strategy
Deactivation response
Post-incident response
A plan for practice drills
Anticipated resources
Mass causality incident planning
An education for all of the above

Emergency Nursing

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Chapter 71

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Scope and Practice of

The Emergency Nurse

Priority Emergency Measures for

Actions to relieve anxiety and provide a sense of security

The triage nurse collects data and classifies

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Gunshot or stab wounds

Persons presenting with respiratory

Principles of Emergency Care

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Principles of Emergency Care

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Management of Patients with

Management of Patients with

Assure airway, breathing, and circulation

Priorities of Care for the Patient

Priorities in the Management of

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Priorities in the Management of

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Control of internal hemorrhage, usually via

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Internal core temperature is 35C or less

Management of Patients with

Use ABCs, remove wet clothing, and

Cardiopulmonary bypass, warm fluid administration,

Passive external rewarming

Warm blankets and over the bed heaters

Note: Cold blood returning from the

Management of Patients with

Poison is any substance that when ingested,

Management of Patients with

Management of Patients with

Poision Ingestion: Contd.

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Management Patients with

Management of Patients with

Management of Patients with

Crisis Intervention: Rape Victims

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Family Violence, Abuse and

Usually do not identify abuser

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Family Violence, Abuse and

Acute awareness for signs of possible abuse/neglect

Family Violence, Abuse and

Mandatory reporting laws

If child or elder abuse is SUSPECTED,

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Emergency Operations Plan

create a plan for emergency preparedness

Emergency Operations Plan

Essential components of the plan:

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