EMERGENCY

NURSING

Prepared By:
EDELWEISS P. JAUM, RN, RM, MAN
EMERGENCY & DISASTER
NURSING

• focus of care is on the

life-threatening issues
ISSUES IN EMERGENCY
NURSING CARE

1. Documentation of Consent & Privacy

 patient must consent to invasive procedures unless he
or she is unconscious or in critical condition and
unable to make decisions.

 If unconscious and brought to ED without family or

friends, this fact must be documented.

 Patients involved in violent events are often provided

with an alias, access to medical record is limited
ISSUES IN EMERGENCY
NURSING CARE

2. Limiting Exposure to Health Risks

 all emergency health care providers must adhere strictly to
standard precautions for minimizing exposures

 increasing number of people infected with hepatitis B and C, HIV,

reemergence of tuberculosis complicated by multi-drug resistant
which makes early identification for patients crucial.

 Nurses are fitted with personal high-efficiency particulate air

(HEPA) filter masks to use when treating patients with airborne
diseases.
ISSUES IN EMERGENCY
NURSING CARE

3. Violence in the Emergency Department

locked the ED against entry if security is
questionable

patients from prison and those under guard

need to be handcuffed to the bed and
appropriately assessed to ensure safety of
hospital staff and other patients. The following
precautions are taken:
ISSUES IN EMERGENCY
NURSING CARE

• handcuff is never released

• a guard is always present in the room
• patient is placed face down on the stretcher to
avoid injury from head-butting, spitting, or biting
• restraints are used on any violent patient as needed
• medication is administered as necessary to control
violent behavior until definitive treatment can be
obtained.
ISSUES IN EMERGENCY
NURSING CARE

 in the case of gunfire in the ED, self-

protection is a priority. There is no
advantage to protecting others if
medical caregivers are injured.
ISSUES IN EMERGENCY
NURSING CARE

4. Providing Holistic Care

 patients and families experiencing sudden
injury or illness are often overwhelmed by
anxiety because they have not had time to
adapt to the crisis
 PRINCIPLES OF
EMERGENCY CARES
1. TRIAGE

• sort patients into groups based on the severity of their

health problems and the immediacy with which those
problems must be treated.
• Three categories: emergent (highest priority with
conditions that are life-threatening), urgent (serious
health problems but not life-threatening; must be seen
in 1 hour) non-urgent (episodic illness that can be
addressed within 24 hours without increased
morbidity)
• Five-Level Triage System: resuscitation,
emergent, urgent, non-urgent, and minor

• Routine ED triage directs all available

resources to the patients who are most
critically ill.
2. ASSESS and INTERVENE

• uses a systematic approach to effectively establishing

and treating health priorities.
• Primary survey follows the ABCD method (airway,
breathing, circulation, disability)
 establish patent airway
 provide adequate ventilation (protect the spine and assess
chest injuries)
 evaluate and restore cardiac output by controlling hemorrhage,
preventing and treating shock, maintaining or restoring
effective circulation.
 Determine neurologic disability.
SAMPLE QUESTION:

1. A client is brought to the emergency

department with burns on the chest, neck and
head. On which of the following assessments
should the nurse place the highest priority of
care?
a. airway patency
b. fluid volume replacement
c. degree of pain
d. extent of injury
2. The emergency department nurse has triaged 4
clients. Which client should be given priority
treatment?
a. the 18-year-old with an impaled knife in the abdomen
b. the 40-year-old with sinus tachycardia and diarrhea times
three days
c. the 39-year-old with an obvious fracture of the right femur
who is complaining of severe pain
d. the 2-year-old stung by a wasp and exhibiting stridor
SHOCK
1. ANAPHYLAXIS
• is a life-threatening hypersensitivity or
pseudoallergenic reaction to an exogenous
agent

• occurs as a result of an extreme decrease

in venous return from the vasodilation and
lowered intravascular volume, which
results in severe cardiovascular and
respiratory compromise.
Assessment:
• Pruritus
• Generalized erythema
• Urticaria
• Angioedema
• Patient may become restless, anxious and
apprehensive.
Treatment:

• find the cause and discontinue it

• administer epinephrine (Adrenaline)
• provide oxygen
• administer antihistamines
• administer corticosteroids
2.CARDIOGENIC SHOCK

• is a special kind of shock during which the heart

does not adequately pump enough blood to the
body’s tissues
• when the heart does not contract adequately,
blood flow to tissues decreases and oxygen
delivery falls
• When oxygen delivery falls below critical levels,
tissues fail to function and eventually break down
(cellular destruction) and die
• When enough tissues die, the entire body
dies

• Most common cause is a heart attack

(myocardial function) that can damage
40% or more of the ventricle
• HYPOXIA in cardiac tissues leads to a further
decrease in cardiac functioning and continues to
compromise cardiovascular function.

• PROGNOSIS is POOR for patients who develop

cardiogenic shock. The risk of dying is between
70% and 80%.

• TREATMENT GOAL: Restore blood flow and

oxygenation to the tissues.
3. HYPOVOLEMIC SHOCK

• most common, is caused from an inadequate

circulating blood volume in the intravascular bed
• the hallmark of all forms of shock is impaired
tissue perfusion.
• The most common cause of hypovolemic shock is
hemorrhage
• The body attempts to compensate for the
decrease in blood volume and decline in tissue
oxygenation through the release of epinephrine
and norepinephrine, which results in
vasoconstriction and an increased in heart rate.
• Hypotension is a late sign. Patients can lose 30%
or more of their intravascular volume before signs
and symptoms appear.
• The best position for the unstable patient in
hypovolemic shock is supine or flat.
• Do NOT attempt to place the patient in the
trendelenburg position becaue it stimulates the
baroreceptor response and aggravates hypoxia
and cerebral venous congestion.
4. NEUROGENIC SHOCK

• is also known as spinal shock

• it is classified as a distributive shock state
• a level T6 and above spinal cord injury is the most
common
• patient develops hypothermia because of
vasodilation and the inability to control body
temperature through vasoconstriction
Treatment:
• Maintain the patient’s ABCs
• Place on a continuous pulse oximeter
• Intubate and secure an airway, if
necessary
• Infuse IV fluids for volume replacement
• Administer vasopressors
• Administer atrophine sulfate, if necessary
• Provide rewarming measures
5. SEPTIC SHOCK

• occurs when sepsis is present

• sepsis occurs when a microbial infection is

present in the blood and signs and
symptoms of severe infection such as
fever, tachycardia, and tachypnea are
present
Treatment:
• Maintain a patent airway
• Administer oxygen
• Monitor hemodynamics
• Provide IV access
• Support BP with fluids and medications
• Obtain cultures
• Administer appropriate antibiotic therapy
TRAUMA AND
EMERGENCY
CARE
1. RAPID SEQUENCE
INTUBATION (RSI)

• is a specialized form of placing an

endotracheal tube (ETT) to provide
ventilation via a secure airway
2. INCREASED INTRACRANIAL
PRESSURE (ICP)

• is a dynamic state that reflects the

pressure of cerebrospinal fluid within
the skull. Increased ICP is described
as pressures >20 mmHg
NORMAL ICP ACCORDING TO
AGE

• adults and older children <10-15 mmHg

• young children 3 to 7 mmHg

• Infants 1.5 to 6.0mmHg

RISKS for Increased ICP

• head injury
• intracranial hematoma
• space-occupying lesion (tumor, abscess,
infection)
• decorticate or decerebrate posturing
• hypoxia
• hypercarbia
• cerebral edema (secondary to surgery,
trauma, hemorrhage)
IMPORTANT!

• dangerous, sustained elevations in ICP

can lead to brainstem compression and
herniation of brain tissue, resulting in
coma and ultimately death.
• body positioning (head in straight alignment – care
should be taken to avoid slight flexion caused by
pillows
• elevation of head of bed < 30 degrees
• prone position and extreme flexion of hips, avoiding
trendelenburg position
• staggered timing and sequence of nursing care
• controlled environmental conditions (quiet, darkened
room)
INTERVENTIONS

• Temperature control
• BP control
• CSF drainage
• Fluid restriction
• Ventilation and airway management
• Medications: osmotic diuretics, steroids,
anticonvulsants, barbiturates, vasoactive drugs (to
increase or decrease BP), sedatives and analgesics
3. Traumatic Brain Injury (TBI)

• occurs when a substantial force strikes the

skull, which can be blunt, penetrating or a
combination of the two
• TBI is one of the leading causes of death
and the most lethal of all trauma-related
injuries, but its survivors also suffer the
greatest disability with long-term effects
and deficits.
• Contributory causes of TBI are associated
with motor-vehicle-crashes (MVC), falls,
and violence
• Five major types of primary TB: skull
fractures, concussion, contusion, diffuse
axonal injury and hematomas
• Skull Fracture – approximately two out of three
patients acquire a mild to severe brain injury. The
fractures are not usually life-threatening but may
disrupt the meningeal layers and allow leakage of
CSF and blood from the ears and nose.
• Concussion is a direct brain injury and is generally
mild but may have underlying pathologic
consequences such as slow subdural bleed that is
not observed until days after the injury.
• Contusions occur when the head suffers a
direct impact with a rigid object.

• Diffuse axonal injury describes extensive

damage involving a wide area of neural
tissues throughout the brainstem and the
cerebrum
INTERVENTIONS

• Airway evaluation
• Pharmacologic treatment
• Ensure cervical spine protection
4. BRAIN ATTACK (acute ischemic
stroke)

• is a sudden neurologic impairment caused

by a decrease in the blood flow to any
vascular territory in the brain.
• It is considered a medical emergency.
• time is critical. Initial recognition of brain
attack symptoms is crucial for the possible
treatment with thrombolytic agents.
• Only a 3-hour window for treatment exists.
5. ACUTE HEMORRHAGE RELATED
TO GUNSHOT WOUND

• First Line Treatment: Infuse lactated

Ringer’s Solution

• “O” negative blood is usually transfused in

the emergent patient without a type and
crossmatch.
6. NEAR-DROWNING

• Drowning is the death of a victim from

suffocation by asphyxiating immersion or
submersion in any fluid or liquid medium
when the cause of death cannot be
attributed to other lethal disorders.
• Risk Factors: hypothermia, inability to swim,
diving accidents, alcohol and drug ingestion,
and exhaustion
• When the victim recovers spontaneously
or is successfully resuscitated (at least
temporarily) near drowning is said to occur
• Hypoxia and acidosis act as myocardial
depressants and precipitate circulatory
collapse
INTERVENTIONS
• excellent, prompt, field-initiated CPR, regardless of
the availability of advanced life support knowledge
increases the chances for survival
• do not attempt to rewarm the victim at the scene
unless the hospital is less than 15 minutes away
• the heart is resistant to drug therapy and
electroconversions when the core temperature is
lower than 300C
Factors that Increase Survival
include
• immediate, quality CPR
• cold water (240C)
• clean water
• short immersion time
• less struggle
• no associated injuries
PRACTICE!

1. When the victim is submersed but has

been recovered and resuscitated, it is
said that he or she has experienced
_____________ drowning.

2. Prompt ______________ is the key

when treating a near-drowning victim.
7. POISONING
• is any substance that, when ingested,
inhaled, absorbed, applied to the skin, or
produced within the body in relatively small
amounts, injures the body by its chemical
action.
• Ingested Poisons may be corrosive.
• Give water or milk to drink for dilution.
measures
• syrup of ipecac
• gastric lavage for the obtunded patient
• activated charcoal administration
• cathartic, when appropriate
Carbon Monoxide Poisoning

• Measures: carry the patient to fresh

air immediately, open all windows
and doors
Loosen tight clothing
Initiate CPR if required, give 100%
oxygen
Prevent chilling
Keep patient quiet
END