EMERGENCY NURSING

Most patient with life- threatening or potentially life-threatening problems arrive at the hospital
through the emergency department. Emergency nursing deals with human responses to any
trauma or sudden illness that require urgent (immediate) intervention to prevent imminent
damage or death

Care in emergency can be provided in any settings, involve person of all ages and with a variety
of problems. However, recognition of life-threatening illness or injury is one of the most
important aspects of emergency nursing. Initiation of interventions to reverse or prevent a crisis
often is a priority before a diagnosis is made.

This process begins with your first patient contact. Prompt identification of patients requiring
immediate treatment and determination of appropriate interventions are essential nurse
competences.

Triage

Triage, a French word meaning “to sort’’, refers to the process of rapidly determining patient
acuity or the process of determining the priority of patients' treatments by the severity of their
condition or likelihood of recovery with and without treatment.

It is one of the most important assessment skills needed by emergency nurse. Most often, you
will confront multiple patients who have a variety of problems. The triage process works on the
premise that patients who have a threat to life must be treated before other patients.

A triage system identifies and categorizes patients so that the most critical are treated first. But
three-level triage system was used in the first period named spot check which include: emergent,
urgent, and not urgent.

Emergent situation: these are potential life threatening which includes: cardiac arrest, severe
chest pain, temperature of 40.5, emergency childbirth/delivering complications, severe
haemorrhage
Urgent situation: They are serious situation but not life threatening if the treatment is delayed
for too long e.g chest pain without respiratory distress, high temperature between 38.9- 40,
major fractures,burns etc

Non-urgent situation: They are not acute situation and are considered minor to moderate e.g
chronic backache, UTI, minor burns etc

But the Emergence Nurses Association [ENA] and American college of emergency physicians
support the use of a five-level triage system known as emergency severity index [ ESI]. This
incorporates concepts of illness severity and resource utilization [e.g., electrocardiogram,
laboratory work, radiology studies, intravenous fluids] to determine who should be treated first.
The ESI includes a triage algorithm that directs you to assign an ESI level to patients presenting
to the ED.

Initially, you assess the patient for any threats to life [e.g., is the patient dying] or presence of a
high-risk situation [e.g., is this a patient who should not wait to be seen]. Next, evaluate patients
who do not meet the criteria for ESI-1 or ESI-2 for the number of anticipated resources they may
need. Assign patients to ESI level3, 4, or 5 based on this determination. Normal vital signs are
required for patients assigned to ESI level 3. Patients with abnormal vital signs may be
reassigned to ESI level 2.
After you complete the initial focused assessment to determine the presence of actual or potential
threaten to life, proceed with a more detailed assessment. A systematic approach to this
assessment decreases the time required to identify potential threats to life and minimizes the risk
of overlooking a life-threatening condition.

A primary survey and a secondary survey are the approaches to use with trauma patients.
However, you can apply these approaches to the assessment of any emergency patient’s
condition throughout the assessment.

Primary survey

The primary survey focuses on airway, breathing, circulation, disability, and

exposure/environmental control. It serves to identify life-threatening conditions related to
airway, breathing, circulation [ABCs], and disability at any point during the primary survey.
When this occurs, start interventions immediately and before moving to the next step of the
survey

A= Airway with cervical spine stabilization and/or immobilization.

Nearly all immediate trauma deaths occur because of airway obstruction. Saliva, bloody
secretions, vomitus, laryngeal trauma, dentures, facial trauma, fractures, and the tongue can
obstruct the airway. Patients at risk for airway compromise include those who have seizures,
near-drowning, anaphylaxis, foreign body obstruction, or cardiopulmonary arrest. If an airway is
not maintained, obstruction of airflow occurs and hypoxia and death will result.

Primary signs and symptoms in a patient with a compromised airway include dyspnea, inability
to speak, presence of foreign body in the airway, and trauma to the face or neck. Airway
maintenance should progress rapidly from the least to the most invasive method.

Assessment

 Clear and open air way

 Assess for obstructed air way
 Assess for respiratory distress
 Check for loose teeth or foreign objects
 Assess for bleeding, vomitus, or edema

Treatment

 Opening of the airway using the jaw-thrust maneuver[ avoiding hyperextension of the
neck],
 Suctioning or removal of foreign body,
 Insertion of a nasophyaryngeal or an orooharyngeal airway[will cause gagging if patient is
conscious], and endotracheal intubation.
 If unable to intubate because of airway obstruction, an emergency cricothyroidotomy or
tracheotomy is performed.
 Ventilate patients with 100% oxygen using a bag-valve-mask [BVM] device before
intubation or cricothyroidotomy.
 Cervical spine is immobilization using rigid cervical collar, backboard,towel rolls, forehead
secured to backboard

B- breathing

Adequate airflow through the upper airway does not ensure adequate ventilation. Many
conditions cause breathing alterations including fractured ribs, pneumothorax, penetrating injury,
allergic reactions, pulmonary emboli, and asthma attacks. Patients with these condition may
experience a variety of signs and symptoms, including dyspnea [e.g., pulmonary emboli],
decreased or asymmetric chest wall movement [e.g., flail chest], decreased or absent breath
sounds on the affected side [e.g., pneumothorax], visible wound to chest wall [e.g., penetrating
injury], cyanosis (e.g., asthma), tachycardia, and hypotension.

Assessment

 Assess ventilation
 Look for paradoxic movement of the chest wall during inspiration and expiration
 Note use of access of accessory muscles or abdominal muscles
 Listen for air being expired through nose and mouth
 Feel for air being expelled
 Observe and count respiratory rate
 Note colour of nail beds, mucous membranes, skin
 Auscultate lungs
 Assess for jugular venous distention and position of trachea

Treatment

 Give supplemental oxygen via appropriate delivery system

 Ventilate with bag valve mask with 100% oxygen if respirations are inadequate or absent
 Prepare to intubate if respiratory arrest
 Have suction available
 If absent breath sounds, prepare for needles thoracostomy and chest tube insertion
 and treatment of the underlying cause

C= circulation.

An effective circulatory system includes the heart, intact blood vessels, and adequate blood
volume. Uncontrolled internal and/or external bleeding places an individual at risk for
hemorrhagic shock.

Assessment

 A central pulse [e.g., carotid] should be checked because peripheral pulses may be absent
due to direct injury or vasoconstriction.
 If you feel a pulse, assess the quality and rate.
 Assess the skin for color, temperature, and moisture.
 Altered mental status and delayed capillary refill [longer than 3 seconds] are the most
significant sign of shock.
 Take care when evaluating capillary refill in cold environments because cold delays
refill.
 Asses for external bleeding
 Measure blood pressure

Treatment
  If absent pulse, initiate cardiopulmonary resuscitation and advanced life support
measures
 If shock symptoms or hypotensive, start initiate infusions of normal saline or lactated
ringers solution
 Control bleeding with direct pressure if appropriate
 Administer blood products if ordered
 Consider autotransfusion if isolate chest trauma
 Consider use of a pneumatic antishock garment or pelvic splint in the presence of pelvic
fracture with hypotension
 Obtain blood samples for type and cross match

D= disability.

Conduct a brief neurologic examination as part of the primary survey. The patient’s level of
consciousness measures the degree of disability.

Brief neurologic Assessment

 Assess level of consciousness by determining response to verbal and\or painful stimuli [e.g.
A simple mnemonic to remember is AVPU; A=alert, V= responsive to voice, P= responsive
to pain, and U=unresponsive, Glasgow Coma scale]
 Assess pupils for size, share, shape, quality, and reactivity

Indentify deformities

 Inspect extremities for any obvious deformities

 Determine range of movement and strength in extremities

Brief pain assessment

 Assess pain e.g provoking factors, quality, region/radiation, severity and time (PQRST)

Treatment

 Periodically reassess level of consciousness, mental status, pupil size and reactivity
  Immobilize [e.g. splint]any obvious deformities
 Periodically reassess pain using standardized pain scale

E= exposure/environmental control.

Remove all trauma patient’s clothing to perform a thorough physical assessment. Once the
patient is exposed, it is important to limit heat loss, prevent hypothermia, and maintain privacy
by using warming blankets, overhead warmers, and warmed IV fluids.

Secondary survey

The secondary survey begins after addressing each step of the primary survey and initiating any
life saving interventions. The secondary survey is a brief, systematic process that aims to identify
all injuries

F= full set of vital signs/focused adjuncts/facilitate family presence.

Obtain a full set of vital signs, including blood pressure (BP), heart rate, respiratory rate, oxygen
saturation, and temperature after the patient is exposed. If the patient has sustained or is
suspected of having sustained chest trauma, or if the BP is abnormally high or low, obtain the BP
in both arms.

At this point, determine whether to proceed with the secondary survey or to perform additional
interventions. The input of other health care team members often influences this decision. The
following focused adjuncts are considered for patients who sustain significant trauma and /or
require lifesaving interventions during the primary survey;

 Continuously monitor electrocardiogram [ECG] for heart rate and rhythm.

 Continuously monitor oxygen saturation [SpO].
 Obtain portable chest x-ray to confirm exact placement of tubes (e.g
endotracheal,gastric).
 Insert an indwelling catheter to decompress the bladder, monitor urine output, and check
for hematuria. Do not insert an idwelling catheter if blood is present at the urinary meatus
(e.g., urethral tear) or if scrotal hematoma or perineal ecchymosis is present. Men with a
 high-riding prostate gland on rectal examination are at risk for a urethral injury. The
physician may order a retrograde urethrogram before inserting a catheter.
 Insert orogastric or nasogastric tube to decompress and empty the stomach, reduce the
risk of aspiration, and test the contents for blood. Place an orogastric tube in the nares of
a patient with significant head or facial trauma as a nasogastric tube could enter the brain.
 Facilitate laboratory and diagnostic studies (e.g., typing and crossmatching, complete
blood count, arterial blood gases etc
 Determine the need for tetanus prophylaxis.

Facilitating family presence [ FP] completes this step of the secondary survey. Research supports
the benefits of FP during resuscitation and invasive procedures to patients, caregivers, and staff.
Patients report that having caregivers present comfort them, serve as a advocate for them,and
help to remind the health care team of their ‘’personhood’’. Caregivers who wish to be present
during invasive produces and resuscitation view themselves as active participants in the care
process. They also believe that they provide comfort to the patients and that it is their right to be
with the patient. Nurses report that family members who participate in FP serve as ‘’patients
helpers’’[e.g., provide support] and ‘’staff helpers’’ [e.g., act as a translation]. It is essential to
assign a member of the health care team to explain care delivered and answer questions should a
caregiver request FP during resuscitation or invasive procedures.

G=Give comfort measures

Provision of comfort measures is of paramount importance when caring for patients in the
Emergency Department. Pain is the primary complaint of most patients who come to the ED.
Many EDs have developed pain management guidelines to treat pain early, beginning at triage.
Pain management strategies should include a combination of pharmacologic (e.g., nonsteroidal
anti-inflammatory drugs, opioids) and nonpharmacologic (e.g., imagery,distraction,positioning)
measures. General comfort measures such as verbal reassurance, listening, reducing stimuli (e.g.,
dimming lights), and developing a trusting relationship with the patient and caregiver should be
provided to all patients in the ED. Additional measures include splinting, elevating, and icing
injured extremities as appropriate.

H=History and head to toe assessment.

The history of the incident, injury, or illness provides clues to the cause of the crisis (e.g., were
the injuries self-inflicted) and suggests specific assessment and interventions. The patient may
not be able to give a history. However, caregivers, friends, witnesses, and prehospital personnel
can often provide necessary informations. Prehospitaly information should focus on the
mechanism and pattern of injury, injuries suspected, vital signs, treatments initiated, and patient
responses.

I=Inspect the posterior surfaces.

The trauma patient should always be logrolled (while maintaining cervical spine immobilization)
to inspect the patient’s posterior surfaces. Inspect the back for ecchymosis, abrasions, puncture
wounds, cuts, and obvious deformities. Palpate the entire spine for misalignment, deformity, and
pain.