Chapter 70

Emergency Nursing Care

Principles and Triage
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Introduction
Emergency
Medical condition requiring immediate or
timely intervention to prevent permanent
disability or death

Trauma
Wound or injury

Emergency nursing
Care of clients who require emergency
intervention
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Introduction (contd.)
Disaster
Situation or event of greater magnitude than
emergency
Unforeseen, serious, or immediate threats to
public health
Natural: fires, earthquakes, floods, hurricanes,
or tornadoes
Man-made: war, terrorism, or contamination of
environment
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Emergency/Disaster
Preparedness
Preparing for emergencies or disasters
Identify who needs to know how to do what

CDC Core Competencies

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Approaches to Emergency Care

Triage
Classification of clients according to condition
or injury to determine priority of need and
treatment

Hospital triage
Establishes priorities and levels of care
needed by clients

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Approaches to Emergency Care

(contd.)
Disaster triage and mass casualty
incidents
System used in event of community disaster
when more victims than care providers
Provides safe and orderly management

Triage priorities on how to save most

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Shock
Condition of profound hemodynamic and
metabolic disturbance
Characterized by inadequate tissue perfusion
Bodys inability to meet tissue demand for oxygen

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Shock (contd.)
Major types
Hypovolemic
Cardiogenic
Distributive
Septic
Anaphylactic
Neurogenic

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Nursing Management
Important considerations
Focus is to identify the type of shock and
initiate interventions as soon as possible

Hypovolemic: restore volume

Cardiogenic: improve myocardial function
Septic: give IV antibiotics and fluid
Neurogenic: give medications for hypotension
Anaphylactic: identify cause

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Cardiopulmonary Emergencies
Emergencies that jeopardize function of
heart and lungs
May result from trauma or illness

Medicalsurgical management
Medical goal: maintain CAB
Intubate as needed

Pharmacological: pain control

Activity: bed rest
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Nursing Management
Important considerations
Initiate CPR if indicated
Remain with the client to reduce anxiety
Administer pain medication as ordered
Suction as necessary to keep airway patent
Monitor vital signs and lung sounds
Encourage turning and deep breathing

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Neurological/Neurosurgical
Emergencies
Include:
Head injuries, spinal cord trauma, strokes or
brain attacks, hypoglycemia, carbon
monoxide poisoning, drug overdose, and
electrolyte imbalance

Medicalsurgical management
Medical: maintain CAB
Pharmacological: oxygen
Activity: semi-Fowlers position
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Nursing Management
Important considerations
Immediately administer oxygen as ordered
Monitor vital signs
Assess GCS score
Maintain the client in a semi-Fowlers position,
or as ordered
Orient to date and time as needed

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Abdominal Emergencies
Diverse
Simple contusion to ruptured spleen
Illnesses from gastroenteritis to GI bleeding

Medicalsurgical management
Medical: IV access, oxygen, maintenance of
CAB, blood products, NG tube, x-ray, and labs
Pharmacological: narcotics for pain
Wound care: sterile saline soaked gauze for
eviceration
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Nursing Management
Important considerations
Administer oxygen and follow agency protocol
for managing CAB
Initiate IV access
Administer analgesics as ordered
Monitor vital signs, bowel sounds, and
abdominal girth
Administer medications
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

MedicalSurgical Management
Treatment
Medical: CAB, IV access, blood and urine
specimens
Surgical: depends on injury
Pharmacological: antibiotics, pain medication
Diet: NPO
Activity: return to full activity as soon as
possible
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Nursing Management (contd.)

Encourage the client to keep the wound and
dressing dry and clean, but instruct how to
remove and change the dressing when dirty
or wet

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Ocular Emergencies
Include:
Foreign bodies, impaled objects, and avulsed
eyeballs

Medicalsurgical management
Medical: primary goal is to restore health of
eye
Surgical: needed for retinal detachment
Activity: initially limited
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Ocular Emergencies (contd.)

Nursing management
Maintain the client in semi-Fowlers position
Instill eye medications and apply an eye patch

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Musculoskeletal Emergencies
Muscle strain
Overstretching of muscle

Sprain
Twisting of joint and partial rupture of
ligaments

Dislocation
Bone displacement from joint

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Musculoskeletal Emergencies
(contd.)
Fracture
Break in continuity of bone

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

MedicalSurgical Management
Treatment
Medical: RICE (rest, ice, compression,
elevation)
Surgical: depends on injury
Pharmacological: pain control
Diet: NPO depending on injury
Activity: depends on injury

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Nursing Management
Important considerations
Immobilize the affected part
Administer analgesic as ordered
Elevate the injured area
Apply ice packs, as ordered
Assess pulse, skin color, capillary refill, ability
to move fingers or toes, and sensation in the
injured area
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Soft-Tissue Emergencies
Minor abrasions, lacerations, puncture
wounds, contusions, bites of all varieties,
and burns
Most do not require emergency care
Some severe

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Soft-Tissue Emergencies
(contd.)
Medicalsurgical management
Medical: prompt intervention, clean, suture,
concern for infection
Pharmacological: pain medication, antibiotics,
etc.
Activity: depends on injury

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Nursing Management
Important considerations
Determine the clients immunization status
Use aseptic technique when cleansing softtissue injuries
Administer analgesic, immunization(s), and
antibiotic

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Nursing Management (contd.)

Encourage the client to keep the wound and
dressing dry and clean, but instruct how to
remove and change the dressing when dirty
or wet

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Poisoning and Overdoses

May be accidental or intentional
Treated as an emergency

Medicalsurgical management
Medical: manage CAB
Pharmacological: depends on incident
Diet: NPO

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Poisoning and Overdoses

(contd.)
Nursing management
Assess for CAB, initiate IV access, and
administer oxygen

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Environmental/Temperature
Emergencies
May be life-threatening
Hypothermia and frostbite can result from
cold temperatures or submersion in cold
water
Heart rate and metabolic rate fall
Cardiac arrest may follow

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

MedicalSurgical Management
Treatment
Medical: rewarming
Pharmacological: IV and oxygen
Diet: fluids

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Nursing Management
Important considerations
Initiate CPR if needed
Monitor vital signs
Establish IV access
Provide oxygen and administer fluid and
electrolytes as ordered
Warm or cool body as indicated
Monitor cardiac response
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Nursing Process (contd.)

Nursing diagnoses include:
Hypothermia
Related to exposure to cold environment/long
submersion in cold water

Hyperthermia
Related to environmental exposure to heat

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Multiple-System Trauma
Injury sustained in more than one body
system
Blunt injuries and penetrating trauma

Medicalsurgical management
Immediately manage cab, control bleeding,
remove clothing to visualize injuries, start IV
line, administer tetanus, and obtain labs and
x-rays
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Nursing Management
Important considerations
Assess and initiate CAB
Establish IV access
Remove the clients clothing for visualization
of injuries
Obtain blood and urine specimens
Assess level of consciousness
Monitor vital signs and neurological status
2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.

Legal Issues
Medical personnel may care for clients
without obtaining informed consent in
emergencies
Good Samaritan laws provide protection
against malpractice to people who stop at
scene of accident and render safe and
appropriate care

2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied,
duplicated, or posted to a publicly accessible website, in whole or in part.