Ateneo de Davao University

College of Nursing, Emergency Nursing

Emergency Nursing:
1. Care given to patients with urgent and critical needs.
2. Care that must be given without delay.
3. Care which involves constant assessment and monitoring of the acutely ill and injured patients

Emergency Nursing: A specialty, because it is care given in a phase when a diagnosis has not been made and
the cause of the problem is not yet known.

According to Emergency Nursing Association (ENA) it involves:

• Assessment, Diagnosis & Treatment of perceived, actual or potential, sudden or urgent, physical or
psychosocial problems that is primarily episodic or acute.

Qualifications of an ER nurse:
• A BSN graduate and holder of a current license to practice nursing in the Philippines.
• Has had specialized education, training, and experience to gain expertise in assessing and identifying
patient’s health care problems in crisis situations.

Basic Nursing Responsibilities:

1. Establish priorities
2. Provide holistic care
3. Monitors and continuously assesses acutely ill and injured patients
4. Document all procedures made
5. Supervise other allied health personnel
6. Support and attend to families
7. Give health teachings to patients and their families in a time-limited and high-pressured care environment
8. Request for and refill supplies
9. Protect self and others:
• Use universal precaution on body fluids
• Use masks and gloves

Nursing in Disaster Condition:

Disaster – is a catastrophe which may be natural in origin or manmade, whether produced accidentally or
by design.

Stages of Disaster:
1. Threat Stage – when situation has a potential of creating crisis but does not show actual condition of peril
2. Warning Stage – it is more specific than the stage of threat and almost assures the reality of disaster
3. Impact – when the disaster is manifested full-blown
4. Recovery – when the assessment of the disaster effects is made, the injured are rescued, and rehabilitation
of people and their lives is begun.

Disaster Management Plan is a community-wide, hospital-wide, or emergency department plan to handle

mass casualty incidents that may occur anytime.

Types of Disaster:
A. NATURAL
• FLOODS
• EARTHQUAKES
• STORMS
• TORNADOES / HURICANE
• EXTREME HEAT OR COLDNESS
• BUSH FIRES
• EPIDEMICS
 B. MANMADE
• STRIKES
• RIOTS
• MASS SHOOTINGS
• HOSTAGE TAKING
• TERRORISM
• DEMONSTRATIONS

C. TECHNICAL
• VEHICULAR ACCIDENTS
• MAJOR INDUSTRIAL ACCIDENT
• BUILDING COLLAPSE
• HAZARDOUS CHEMICAL INCIDENTS
• FIRE INCIDENTS

Disaster Nursing Management:

1. Critical thinking is Important.
• Nurse should remain calm
• Rapidly Assesses Situations
• Consider Options
• Enact Emergency Response Plan
• Ability to TRIAGE
2. Collaboration with other Agencies
• Communication
• Delegation
• Coordination
• Negotiation

Components of Emergency Nursing:

• Establish priorities (Triage and Nursing Assessment)
• Health History and Complete Head-to-toe assessment
• Formulate Nursing Diagnoses
• Planning/Implementation
• Nursing Documentation
• Patient Transport

Triage:
• Comes from French word “trier” meaning “to sort”
• Used to sort patients into groups based on:
– severity of their health problems
– immediacy with which these problems must be treated
• Classification of clients presenting to the ER for the purpose of prioritizing treatment
• Looks at medical needs and urgency of each individual patient
• Sorting based on limited data acquisition
• Also must consider resource availability

Categories of Triage:
1. Emergent – those conditions that require immediate care and intervention, increased risk of mortality (death) or
threat to life, limb, or vision.

2. Urgent – those conditions that require care ASAP, generally within 1 hour and have the potential for causing
deterioration of health state if not treated immediately.
3. Non-urgent – those conditions that require routine care that can be delayed for greater than 2 hours without the
possibility of deterioration

Critical Qualities of a Triage Nurse

• Expert Assessment Skills
• Non-judgmental Communication
• Excellent interviewing techniques

Coding of Triage
1. Emergent: Red, Priority I: life, limb, eye threatening that needs immediate attention, monitoring is continuous.
• Chest pain
• Cardiac arrest
• Severe respiratory distress
• Chemicals in eye
• Limb amputation
• Trauma
• Acute neurologic deficits

2. Urgent: Yellow, Priority II: needs treatment in 20 minutes to 2 hours, monitoring is every 30-60 minutes.
• Fever more than 40C (104F)
• diastolic BP more than 130mmHg
• kidney stones
• simple fracture
• abdominal pain
• asthma without respiratory distress
3. Non-urgent: Green, Priority III: can wait hours or days, monitoring is every 1-2 hours.
• Sprain
• Minor laceration
• Cold symptoms
• Rash
• Simple headache

4. Dead: Black (sometimes still with life signs but injuries are incompatible with survival)

Priorities of Treatment:
1. First Priority – individuals needing immediate attention to save life
• Any wound interfering with airway or causing airway obstruction.
• Sucking chest wounds, tension pneumothorax and maxillo-facial wounds in which asphyxia is present
or an impending threat.
• Any wound requiring immediate pressure for bleeding
• Shock due to major hemorrhage, to wounds of any organ systems, fractures, etc.

2. Second Priority – individual needing early surgery

• Visceral injuries including perforation of GI tract
• Wounds of the biliary and pancreatic system
• Wounds of the GU tract and thoracic wounds without asphyxia
• Vascular injuries requiring repair and/or in which the use of a tourniquet is necessary
• Closed cerebral injuries with increasing loss of consciousness

3. Third Priority – patients who require surgery but can tolerate a delay
• Spinal injuries in which decompression is required
• Lesser fracture & dislocations
• Minor injuries of the eye
• Soft tissue wounds in which debridement is necessary, but in which muscle damage is less than major
• Maxillo-facial injuries without asphyxia

Priorities for patient with an emergent or urgent health problem:

1. Stabilization
2. Provision of critical treatments
 3. Prompt transfer to the appropriate setting (ICU, OR, General Care Unit)

Why Should Planners Plan For Good Triage?

1. Helps in resource planning and allocation.
2. Provides an objective framework for stressful and emotional decisions, helping rescue workers to be more
efficient and effective.

TRIAGE MOTTO:
1. Daily Emergencies: “Do the Best for Each Individual”
2. Disaster Settings: “Do the greatest good for the greatest number. Maximize survival”

Components of ER Nursing:
1. Establish Priorities: by using triage and accurate assessment.
2. Formulate Nursing Diagnoses
3. Plan/Implement
4. Documentation

1. Establish Priorities: by using triage and accurate assessment.

I. Primary Survey - The rapid initial assessment of the client’s presenting symptoms.
A - Airway
B - Breathing
C - Circulation
D - Disability

• It determines the presence of life-threatening conditions while simultaneously intervening.

• Purpose – to immediately identify any problem that poses a threat, immediate or potential
to life, limb or vision.
• Procedure - information is gathered primarily through objective data.
• If abnormalities are found, immediate interventions such as CPR and ACLS must be
instituted to aid in preserving the client’s life, limb or vision.

A – AIRWAY: Maintain patent airway

a. e.g. head tilt/chin lift, jaw thrust, suctioning, oropharyngeal or nasotracheal
intubation or tracheostomy
b. Cervical spine immobilization should be maintained

B – BREATHING
a. Provide adequate ventilation, employing resuscitation measures when necessary
b. Application of oxygen via mask or bag-valve mask device
c. Assisting in chest tube insertion or endotracheal intubation
d. –Covering of open chest wound with occlusive dressing

C – CIRCULATION
a. CPR
b. Evaluate and restore cardiac output by:
• controlling hemorrhage
• preventing and treating shock
• maintaining and restoring effective circulation

c. Control hemorrhage and blood/fluid loss by:

 applying direct pressure (external bleeding)
 insertion of IVF, fluid volume replacement with NSS, Blood Transfusion, etc.

D – DISABILITY
a. Deformity-Open Wound-Tenderness-Swelling (DOTS)
b. Determine neurologic disability by completing a brief neurological assessment
c. Determine baseline functioning, potential life threatening complications.
d. Check LOC using GCS or RLS

II. Secondary Survey –

 • Identify any other non-life threatening problems
• Both subjective information and objective data are obtained.
• Cervical immobilization is maintained at all times during secondary assessment.

1. Neurologic Assessment
1. Level of consciousness
2. Orientation to person, place, time, and event

3. Reaction Level Scale (RLS)

1 - Alert, fully conscious
2 - Drowsy, slightly confused
3 - Very drowsy, very confused, arousable to pain
4 - Unconscious, localizes
5 - Unconscious, withdraws
6 - Unconscious, decorticate
7 - Unconscious, decerebrate
8 - No reaction

4. Glasgow Coma Scale (GCS)

• Eye opening
• Pupillary size, equality and reaction to light and accommodation
• Verbal response
• Motor movement and strength of hand grips and pedal pulses

1. Best Eye Opening

• Spontaneous -4
• To voice -3
• To pain -2
• No response -1

2. Best Verbal Response

• Oriented, conversant -5
• Confused -4
• Inappropriate words -3
• Incomprehensible sounds -2
• No response -1

3. Best Motor Response

• Obeys command -6
• Localizes pain -5
• Withdraws (to pain) -4
• Flexion (decorticate) - 3
• Extension (decerebrate) - 2
• No response -1

5. Pediatric brief neurologic assessment

• A – Alert – the child is awake, alert & needs no stimulus to respond to the
environment
• V – Verbal – the child requires a verbal stimulus to elicit a response
• P – Pain – the child require a painful stimulus to evoke response
• U – Unresponsive – the child is unresponsive to any applies stimulus