NCM118 LECTURE

II. NURSING CARE OF CLIENTS WITH LIFE THREATENING CONDITIONS, ACUTELY ILL / MULTI-ORGAN
PROBLEMS, HIGH ACUITY AND EMERGENCY SITUATION
HANDOUT

A. HIGH ACUITY AND EMERGENCY SITUATION

1. DEFINITION OF TERMS:
a. Emergency
• EMERGENCY is a serious situation or occurrence that happens unexpectedly and
demands immediate action (Webster)
• EMERGENCY is a serious medical or surgical condition that poses an immediate risk to
health, life, property or environment requiring immediate or timely intervention to
prevent permanent disability or death (Medical Dictionary)
• EMERGENCY Any condition that — in the opinion of the patient, his family, or whoever
assumes the responsibility of bringing the patient to the hospital — requires immediate
medical intervention. This condition continues until the determination has been made
that the patient’s life or wellbeing is not threatened.
• EMERGENCY NURSING
A nursing specialty that focuses on the care of patients who require prompt medical
attention to avoid long-term disability or death. It involves the assessment, diagnosis,
and treatment of perceived, actual or potential, sudden or urgent, physical or
psychosocial problems that are primarily episodic or acute

b. High Acuity and Emergency Situation

• Conditions that may result to patient mortality if left unattended in a brief period of
time.
• Conditions that warrant immediate attention, WITHOUT DELAY, for the reversal of
disease process and prevention of further morbidity and mortality
o ACUITY
▪ Degree of acuteness
▪ Patient acuity simply refers to the patient’s risk level
• Whether high or low
▪ The higher the risk acuity the patient has, the higher attention and
therapeutic management is required
▪ Each Facility uses a rating scale or description table to determine
patient’s acuity level
• There are NO universal acuity scales
• Facilities and departments may develop their own
▪ Serves as a basis of prioritizing patient for ICU placement and level of
care

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 Prioritization of Admission, Discharge, and Triage of Acutely Ill Patients in an ICU
Priority for Description of Patient Characteristics
ICU Placement
Priority 1 The patient is acutely ill, unstable, and requires intensive treatment and
monitoring that cannot be provided outside of the ICU (mechanical
ventilation, continuous vasoactive drug infusions).

There are no limits on the extent of intended interventions.

Examples may include postoperative or acute respiratory failure patients

requiring mechanical ventilator support, and shock or hemodynamically
unstable patients receiving invasive monitoring and/or vasoactive drugs.
Priority 2 The patient requires intensive monitoring and may potentially need
immediate intervention. There are no limits on the extent of intended
interventions.

Examples include patients with chronic comorbid conditions who develop

acute severe medical or surgical illness
Priority 3 The patient is critically ill and unstable, with a reduced likelihood of recovery
because of underlying disease or the nature of the acute illness.

The patient may receive intensive treatment to relieve acute illness; however,
limits on therapeutic efforts may be set, such as no intubation or
cardiopulmonary resuscitation.

Examples include patients with metastatic malignancy complicated by

infection, cardiac tamponade, or airway obstruction.
Priority 4 This patient is generally not appropriate for ICU admission.

Determination of admission should be made on an individual basis, under

unusual circumstances, and at the discretion of the ICU director.

Examples include patients with peripheral vascular surgery, stable diabetic

ketoacidosis, or conscious drug overdose, as well as patients with terminal and
irreversible illness facing immediate death.
Data from American College of Critical Care Medicine (ACCM) (ACCM, 1999)

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 ACCM Definitions of ICU Levels of Care
ICU LEVEL Description of Services, Personnel
Level I Hospitals with ICUs that provide comprehensive care for patients with a wide
range of disorders.

Sophisticated equipment is available.

Units are staffed with specialized nurses and HCPs with critical care training.

Comprehensive support services are available and include pharmacy,

respiratory therapy, nutritional support, social services, and pastoral care.

These units may be located within an academic teaching hospital or may be

community based.
Level II Hospitals with ICUs that have the capability of providing comprehensive care to
most critically ill patients but not to specific patient populations (neurosurgical,
cardiothoracic, trauma).
Level III Hospitals with ICUs that have the ability to provide initial stabilization of
critically ill patients but are limited in their ability to provide comprehensive
care for all patients. These hospitals are able to care for ICU patients requiring
routine care and monitoring
Data from American College of Critical Care Medicine (ACCM) (ACCM, 2003)

o High Acuity Patients

▪ Requires frequent observation to ensure that they improve or remain
stable.
▪ On close watch - decline quickly,
▪ Triaging is essential to know the level of patient acuity –
▪ Keen triaging is therefore a must
o High Acuity Environment
▪ High-acuity-care environments include any acute-care areas in which
complex patients with unpredictable outcomes are managed regardless
of the exact environment
▪ High-acuity units and facilities - requires higher staffing levels.
▪ Nurse managers often use acuity scales to decide how many nurses they
need for particular shifts
o High Acuity Nurse
▪ The nurse caring for the high-acuity patient in a high acuity environment
capable of analyzing clinical situations, make decisions based on this
analysis, and rapidly intervene to ensure optimal patient outcomes
▪ The nurse is the only member of the healthcare team who remains at
the bedside and, as a result, is frequently the one who coordinates
patient care.
▪ The nurse is often the first member of the healthcare team to detect
early signs of an impending complication. Constant surveillance by the
nurse involves assessing and monitoring the patient for signs of subtle
changes over time. Often such changes in a patient’s condition are clues
of a possible impending complication.
▪ The prevention of complications is one of the primary goals of the acute-
care nurse.
▪ Ensuring patient safety in high acuity environment
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 ▪ Evidence suggests that constant surveillance by nurses reduces mortality
and life-threatening complications in the hospitalized patient (Shever,
2011)

2. TRIAGE
• French verb “trier” meaning to sort or to choose
• It’s the process by which patients are classified according to the type and urgency of
their conditions to get the
o Right patient to the
o Right place at the
o Right time with the
o Right care provider

a. Triage Categories
• Non disaster or E.D Triage: Usually in Hospital / ER setting
o To provide the best care for each individual patient.
o The primary objectives of an ED triage are to:
▪ Identify patients requiring immediate care.
▪ Determine the appropriate area for treatment
▪ Facilitate patient flow through the ED and avoid unnecessary
congestion.
▪ Provide continues assessment and reassessment of arriving and waiting
patients.
▪ Provide information and referrals to patients and families.
▪ Allay patient and family anxiety and enhance public relations
• Multi-casualty/disaster Triage: Usually outside hospital environment
o Provide the most effective care for the greatest number of patients.

b. Basic Components of Triage

• Assessment
o (An “across the room assessment”)
▪ Visualizing the patient's appearance as he or she enters the facility
▪ Upon the patient's arrival, quick identification of any life-threatening
conditions begins
o The triage nurse must scan the area where patients enter the emergency door,
even while interviewing another patient.
o The triage antenna should be seeking clues to problems in all people who enter
the triage area
o Primary Survey / Assessment: To identify obvious life threat conditions
▪ Air way and Cervical Spine Immobilization
• Is the airway clear and patent?
• The tongue often obstructs the airway in unconscious patients.
• Findings:
o Abnormal airway sounds, strider, wheezing grunting
o Unusual posture e.g.. Sniffing position, inability to
speak, drooling or inability to handle secretion

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 • Intervention/s:
o The cervical spine should be stabilized by being
manually held until a hard cervical collar is placed
▪ Breathing
• If the patient is breathing on his own, at what rate, depth, and
effectiveness?
• Findings:
o Altered skin signs, cyanosis, dusky skin, tachypnea,
bradypnea, or apnea periods, retractions, use accessory
muscles, nasal flaring, grunting, or audible wheezes
• Intervention/s:
o Ensure adequate bilateral ventilation
▪ Circulation
• A systolic blood pressure (SBP) may be assessed when palpating
for pulses. A radial pulse is palpable when the SBP is greater
than 90, while a carotid or femoral pulse will be present if the
SBP is greater than 60. In addition, the nurse should be checking
the skin color, monitoring oxygen saturation as well as central
and peripheral capillary refill time, and noting any obvious
sources of bleeding
• Findings:
o Altered skin signs, pale, mottling, flushing
o Uncontrolled bleeding
• Intervention/s:
o Immediate oxygenation
o Immediate control of source of bleeding
▪ Disability
• Refers to the neurovascular status of the trauma patient.
• What is the level of consciousness of the patient?
• What are the size, shape, equality, and reactivity to light of the
patient’s pupils?
• Is the patient alert?
• Does the patient respond to verbal stimuli or painful stimuli?
• Is the patient unresponsive?
• The Glasgow Coma Scale (GCS) is quickly obtained by noting the
best eye response, best verbal response, and best motor
response.
• Findings:
o Severe Head Injury----GCS score of 8 or less
o Moderate Head Injury----GCS score of 9 to 12
o Mild Head Injury----GCS score of 13 to 15
(Adapted from: Advanced Trauma Life Support: Course
for Physicians, American College of Surgeons, 1993).
• Intervention/s:
o A general rule with the GCS less than 8, intubate

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 ▪ Exposure / Environment
• Removing the clothing of the patient to check for other injuries
while at the same time preventing heat loss with heated
blankets, overhead warmers, a warm room, and/or warmed
intravenous fluids

This format of assessment is ongoing throughout patient care, ensuring that the
priorities of assessment and continuous intervention are effective.

o Secondary Survey / Assessment

▪ Full set of Vital Signs and Family Members
• F is for a full set of vital signs, and family members of the patient
need to be communicated with regarding the patient. The ENA
supports family presence during invasive procedures and
resuscitative efforts; however, the nursing team should ensure
the family member is supported by a nurse or colleague to
answer questions and provide a comforting presence.
▪ Give Comfort Measures
• Comfort comes in the form of physical and emotional comfort.
• Physical comfort might consist of pain relief both in the form of
pharmacological or alternative methods and, if possible,
repositioning, distracting, and touching the patient. Research
reflects that, although we are excellent at anesthetizing our
trauma patients, we underestimate their need for pain control.
• Emotional comfort may be provided in the form of reassurance
both physical and verbal, listening to the patient, and relaying
information to the patient’s family and friends
▪ History and Head to Toe Assessment
• After a major part of the assessment has been done, a head-to-
toe assessment is very important to identify any additional
injuries. The head-to-toe inspection consists of a systematic
inspection beginning with the patient’s head and face, moving
down the neck to the clavicles, shoulders, chest, abdomen, and
flanks, then moving on to the pelvis and perineum and on to the
extremities. The head-to-toe assessment comprises a visual as
well as manual assessment and auscultation of the appropriate
areas
• History includes
o Allergies
o Medications
o Past medical history
o Last meal
o Events surrounding injury
▪ Inspect Posterior Surface
• Most patients will arrive on a long backboard. It is important to
log roll the patient and inspect the posterior surfaces,
controlling any bleeding and documenting findings

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 • The Triage Decision
Is accomplished based on Across the Room Assessment. Appropriate patient’s acuity is
identified.
o Triage Levels – The Canadian E.D. Triage and Acuity Scale
▪ 1- Resuscitation
• Threat to life
• Time for nurse assessment: IMMEDIATE
• Time for physician assessment: IMMEDIATE
• Examples:
o Cardiac and respiratory arrest
o Major trauma
o Active seizure
o Shock
o Status Asthmaticus
▪ 2- Emergent
• Potential threat to life, limb or function
• Time for nurse assessment: IMMEDIATE
• Time for physician assessment: <15 minutes
• Examples:
o Decreased level of consciousness
o Severe respiratory distress
o Chest pain with cardiac suspicion
o Over dose (conscious)
o Severe abdominal pain
o G.I. Bleed with abnormal vital signs
o Chemical exposure to eye
▪ 3- urgent
• Condition with significant distress
• Time for nurse assessment: < 20 minutes
• Time for physician assessment: <30 minues
• Examples:
o Head injury without decrease LOC but with vomiting
o Mild to moderate respiratory distress
o G.I. Bleed not actively bleed
o Acute psychosis
▪ 4- less urgent
• Conditions with mild to moderate discomfort
• Time for Nurse assessment <1h
• Time for physician assessment < 1h
• Examples:
o Head injury, alert, no vomiting
o Chest pain, no distress, no cardiac susp.
o Depression with no suicidal attempt

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 ▪ 5- Non urgent
• Conditions can be delayed, no distress
• Time for nurse and Physician assessment = more than 2h
• Examples:
o Minor trauma
o Sore throat with temp. < 39

c. The Triage Nurse

• A specially-trained Registered Nurse who is responsible for assessing patients and
establishing the level of care that they require, based of patient’s acuity. They are
essential in any health setting that provides emergency health care to facilitate patient
flow through the department
• The Triage Nurse provide professional nursing assessments, prioritize treatments
according to the urgency of need, initiate medical care, reevaluate condition
• Characteristics of Triage Nurse
o Extensive knowledge to emergency medical treatment
o Adequate training and competent skills, language, terminology
o Ability to use the critical thinking process
o Good leadership skills
o Good decision maker
• Responsibilities of Triage Nurse
o Ensuring patient safety in high acuity environment
o Maintain privacy and confidentiality
o Visualize all incoming patients even while interviewing others.
o Maintain good communication between triage team, patient, family and
treatment area
o Use all resources to maintain high standard of care
▪ Technology
▪ Staff
▪ Supplies
• Roles of Triage Nurse
o Facilitator
o Technician
o Coordinator
o Crowd control.
o Communicate with team leader and seek feedback on decisions.
o Least:
▪ Teaching - avoid lecturing

d. Importance of Re-Triage
• Patients who may have presented without cardinal signs of severe illness may develop
them during long waits.
o Reassess the patient within 1-2hours of initial triage and continue to re-assess
on a regular basis
o Patient should wait no longer than 5 minutes for triage
o If in doubt about a category, choose the higher acuity to avoid under triaging a
patient
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 3. CONDITIONS CONSIDERED AS HIGH ACUITY AND EMERGENCY SITUATION
• Respiratory Emergencies
• Respiratory Failures & ARDS
• Shock
• SIRS and MODS
• Burns
• Cardiac Emergencies: Angina and MI
• Neurologic Emergencies: Stroke & Traumatic Brain Injury
• Hepatic coma
• DKA/HHNK
• Thyroid Crisis & Adrenal Crisis
• Renal failure/End Stage Renal Disease

4. Nursing Diagnoses of Patients with High Acuity and Emergency Situation

• Ineffective airway clearance related to tracheobronchial obstruction
• Ineffective breathing pattern related to trauma
• Deficient fluid volume related to active fluid loss due to bleeding
• Acute pain related to trauma
• Risk for infection related to inadequate primary defenses
• Risk for ineffective tissue perfusion: peripheral, renal, gastrointestinal, cardiopulmonary,
or cerebral related to hypovolemia, reduced arterial flow, and cerebral edema

Reference/s:

1. Medical-Surgical Nursing Concepts for Interprofessional Collaborative Care, 9th

edition, 2018, Single Volume by Donna D. Ignatavicius, M. Linda Workman Cherie
Rebar
2. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 13th edition by
Smeltzer, Suzanne C and Bare Brenda
3. High-Acuity Nursing, 6th edition (Global edition), 2015, by Kathleen Dorman Wagner
and Melanie G. Hardin-Pierce

Prepared by Prof. Amelia Z. Manaois for Arellano University College of Nursing to be used as Instructional Material only for NCM118 (LEC).
Refrain from reproducing this material without the consent of the preparer and the AU-CON