EMERGENCY NURSING ● Members of the emergency health
care staff work as a team in
- Emergency nursing is a nursing
performing the highly technical,
specialty that focuses on the care of
hands-on skills required to care for
patients who require prompt medical
patients in emergency situations
attention to avoid long-term disability
(Emergency Nurses Association,
or death.
2013).
- It involves the assessment, diagnosis,
Emergency Nurse
and treatment of perceived, actual
or potential, sudden or urgent, ● Expert in assessing and identifying
physical or psychosocial problems patients’ health care problems in
that are primarily episodic or acute. crisis situations.
Emergency Management ● Has had specialized education,
training, experience, and expertise in
● Emergency management
assessing and identifying patients’
traditionally refers to care given to
health care problems in crisis
patients with urgent and critical
situations.
needs.
● In addition, the emergency nurse
● However, because many people
establishes priorities, monitors and
lack access to health care, the
continuously assesses patients who
emergency department (ED) is
are acutely ill and injured.
increasingly used for non-urgent
problems, therefore, the philosophy ● They also support and attend to
of emergency management has families, supervise allied health
broadened to include the concept personnel, and educate patients and
that an emergency is whatever the families within a time limited, high
patient or the family considers it to pressure care environment.
be.
● Nursing interventions are
● Care that must be rendered without accomplished interdependently, in
delay. consultation with or under the
direction of a physician or advanced
● The strengths and roles of nursing
practitioner, such as a nurse
and medicine are complementary in
practitioner or physician assistant.
an emergency situation.
- Appropriate nursing and
medical interventions are
anticipated based on assessment
data.
Principles of Emergency Nursing Issues in Emergency Nursing Care
✓ ESTABLISH a patent AIRWAY LIMITING EXPOSURE TO HEALTH RISKS
and provide adequate
VENTILATION ➢ Health care providers are at
increased risk for exposure to
✓ CONTROL HEMORRHAGE, and
communicable diseases
PREVENT and MANAGE SHOCK
through blood or other body
✓ MAINTAIN and RESTORE fluids. This risk is further
effective CIRCULATION compounded in the ED
because of the common use of
✓ EVALUATE the NEUROLOGICAL invasive treatments. All
STATUS of the client emergency health care
providers should adhere strictly
✓ Carry out a RAPID INITIAL and
to standard precautions for
ongoing PHYSICAL
minimizing exposure.
ASSESSEMENT
✓ Start CARDIAC MONITORING ➢ Increasing numbers of people
infected with hepatitis, human
✓ PROTECT and CLEAN WOUND immunodeficiency virus (HIV),
tuberculosis, and other
✓ IDENTIFY the significant
infectious diseases.
MEDICAL HISTORY and
ALLERGIES
VIOLENCE IN THE EMERGENCY
✓ DOCUMENT the findings in DEPARTMENT
medical records.
➢ Staff members encounter
patients who may be violent
Seek emergency care for: because of the effects of
substance abuse, injury, or
Large numbers of people seek other emergencies, they may
emergency care for serious, life-
also encounter other violent
threatening conditions such as:
situations.
● Cardiac dysrhythmias
● Acute coronary syndrome ➢ Safety first health care provider
● Acute heart failure
● Pulmonary edema SAFETY is the FIRST PRIORITY
● Stroke
- For prisoners, the hand or
ankle restraint (handcuff) is
never released
- Mask can be placed on the family or friends, this fact must
patient be documented.
- Nonrestraint techniques -
talking with the patient, ➢ After treatment, notations are
minimizing environmental made on the record about the
stimulation. patient’s condition on
- Distance discharge or transfer and
- Not wear items that can be about instructions given to the
grabbed by the patient patient and family for follow-up
- Objects should not be left care.
within patient reach; even an
PROVIDING HOLISTIC CARE
intravenous (IV) line spike can
become a tool of violence - ➢ Sudden illness or trauma is a
Courses on safety stress to physiologic and
psychological homeostasis
➢ There is no advantage to that requires physiological and
protecting others if health care psychological healing.
providers are injured
➢ Patients and families
DOCUMENTATION OF CONSENT
experience real and terrifying
AND PRIVACY
fear of death, mutilation,
➢ Consent to examine and treat immobilization, and other
the patient is part of the ED assaults on their personal
record. The patient needs to identity and body integrity.
give consent for invasive
procedures (e.g., ➢ Assessment of the patient and
angiography, lumbar family’s psychological function
puncture) unless he or she is includes evaluating emotional
unconscious or in a critical expression, degree of anxiety,
condition and unable to make and cognitive functioning.
decisions.
➢ Patients and families
➢ Patient must consent to experiencing sudden injury or
invasive procedures unless illness are often overwhelmed
unconscious or in critical by anxiety because they have
condition. not had time to adapt to the
crisis
➢ If the patient is unconscious
and brought to the ER without ➢ The stages begin with anxiety
and progress through denial,
remorse and guilt, anger, grief, ○ sentinel event
and reconciliation. (unanticipated events that
result in patient harm) include
➢ The initial goal for the patient delays to care and medication
and family is anxiety reduction, errors
a prerequisite to effective and
FAMILY – FOCUSED INTERVENTIONS
appropriate coping.
➢ The family is kept informed
about where the patient is,
PATIENT – FOCUSED INTERVENTIONS
how he or she is doing, and the
➢ Those caring for the patient care that is being given.
should act confidently and
competently to relieve anxiety. ➢ Anxiety and denial (Family
➢ Reacting in a warm manner members are encouraged to
promotes a sense of security. recognize and talk about their
➢ Unconscious patient should be feelings of anxiety. Asking
treated conscious questions is encouraged.)
- Clinicians caring for the
patient should act confidently ➢ Encouraging family members
and competently to relieve to stay with the patient, when
anxiety and promote a sense possible, also helps allay their
of security. anxieties
- Human contact and
Challenges in Emergency Nursing
reassuring words reduce the
panic ➢ Stress and Burnout: The fast-
○ Patient who is paced, high-pressure
unconscious should be treated environment can lead to
as if conscious—that is, the emotional and physical strain.
patient should be touched, Nurses must manage stress
called by name, and given an while maintaining focus on
explanation of every patient care.
procedure that is performed
○ Patient regains ➢ Resource Limitations: Working
consciousness, the nurse in settings with limited
resources (e.g., equipment,
should orient the patient by
space) can require creative
stating their name, the date,
problem-solving and
and the location. This basic
adaptability.
information should be
provided repeatedly, as ➢ Triage Decisions: Nurses often
needed, in a reassuring way. have to make critical decisions
about which patients should - Community and Transitional
be seen first based on the Services
severity of their condition,
which can be ethically ➢ This is particularly important
challenging. for patients who may need
assistance, such as those
who are older adults or
Caring for ER NURSE those with disability.
❖ Focus on the needs of ➢ Before discharge, some
the staff especially after patients require the services
stressful and serious of a social worker to help
events. them meet continuing
❖ It is important to health care needs.
remember that all staff
may not necessarily ➢ Emergency medical system
respond in the same (EMS) personnel provide in-
way; an event that is home visits, without
stressful to one person emergency calls, to identify
may not be the same to needs and provide
another. education and in-home
❖ Compassion fatigue care. If necessary, they can
also transport patients to
the ED.
Emergency Nursing and The
Continuum of Care SPECIAL CONSIDERATIONS
- Discharge Planning - Gerontologic
➢ Before discharge, Considerations
instructions for continuing The nurse should give
care are given to the attention to the patient’s
patient and to the family or feelings of anxiety and fear.
significant others.
The nurse should assess the
➢ Instructions should psychological resources of
include information about the patient and anticipate
prescribed medications, discharge needs.
treatments, diet, activity,
and when to contact a - Obesity Considerations
health care provider or The availability of
schedule follow-up appropriately sixed
appointments. equipment.
Nursing in Disasters their care afterwards would divide
the victims into 3 categories:
● Another filed in emergency nursing. ○ Those who are likely to live
regardless of what care they
● With the increasing use of weapons receive.
and terror, and mass destruction, ○ Those who are unlikely to live
both internationally and at home, the regardless of what care they
emergency nurse must recognize receive.
and treat patients exposed to ○ Those for whom immediate
biological and other weapons, care might make a positive
anticipating nursing care in the event difference in outcomes.
of a mass casualty incident, from
natural causes or Goals of Triage
terrorist event.
✓ Rapidly identify patients with
Principles of Emergency Care urgent, life-threatening
(TRIAGE and ASESS & INTERVENE) conditions
TRIAGE ✓ Assess/determine severity and
acuity of the presenting
● From the french word trier meaning problem
“to sort”.
✓ Direct patients to appropriate
● In the daily routine of the treatment areas
emergency department, triage is
used to sort patients into groups ✓ Re-evaluate patients awaiting
based on the severity of their health treatment
problems and the immediacy with
which these Advantages of Triage
problems must be treated.
✓ Streamlines patient flow.
● The term triage may have ✓ Reduces risk of further
originated during the Napoleonic injury/deterioration.
wars from the work of Dominique ✓ Improves communication and
Jean Larrey. public relations.
✓ Enhances teamwork.
● The term was used further during ✓ Identifies resource
World War 1 by French doctors requirements.
treating the battlefield wounded at ✓ Establishes national
the aid stations behind the front. benchmarks.
● Those responsible for the removal of
the wounded from the battlefield or
Triage Acuity Determinants • What do you think "resources"
means in this context?
● Chief complaint.
● Brief triage history. Triage Categories
● Injury or illness (signs &
symptoms).
● General appearance.
● Vital signs.
● Brief physical appraisal at
triage.
Triage Process
Assess and determine the
severity or acuity of the
presenting problem.
Process the patient into a
triage level.
Determine and direct the
patient to appropriate
treatment areas.
Effectively and efficiently
assign appropriate human
health resources.
Triage Assessment
TYPES AND LEVELS OF TRIAGE
- Chief complaint.
- Brief triage history
- Injury or illness (signs &
• 3 LEVEL TRIAGE – basic triage
symptoms) • EMERGENCY SEVERITY INDEX (ESI) –
- General appearance.
based on severity and resources needed
- Vital signs.
- Brief physical appraisal at
triage. • CANADIAN TRIAGE AND ACUITY SCALE
(CTAS) – based on how often they are re-
Initial Triage Assessment
assessed
• First question: Is the patient • SIMPLE TRIAGE AND RAPID TREATMENT
dying? (START) – mass casualty situations and
• Second question: Can the disasters
patient wait?
• Third question: How many
resources will they need?
BASIC TRIAGE SYSTEM RESOURCES IN TRIAGE
A basic and widely used triage Resources:
system that has been in use for ● Labs (blood, urine)
many years, has 3 categories: ● EKG, X-rays
● CT, MRI, U/S
● Emergent ● IV fluids(hydration)
- Highest priority ● IV or IM or nebulized meds
- Life threatening ● Simple procedure =1 (lac
conditions repair, foley)
- Must be seen ● Complex procedure =2
immediately (conscious sedation)
● Specialty consultation
● Urgent
- Serious health problems Not Resources
but not immediately life- ● H & P (including pelvic)
threatening. ● Point-of-care testing
- Must be seen within 1 ● Saline lock
hour. ● PO meds
● Tetanus immunization
● Non-urgent ● Prescription refills
- Episodic illnesses that ● Simple wound care
can be addressed within (dressings, recheck)
24 hours without ● Crutches, splints, slings
increased morbidity. ● Phone call to PCP
EMERGENCY SEVERITY INDEX
(ESI)
Emergency Severity Index (ESI) Levels o Syncope
o Chronic condition
ESI Level 1: Immediate exacerbation
• Characteristics: o Possible fractures
o Life-threatening o Skin infections
conditions ESI Level 4: Less Urgent
o Require immediate • Characteristics:
interventions o Very stable patients
o Highest priority patients o Can wait 1+ hours
• Examples: o Require 1 resource
o Cardiac arrest • Examples:
o Respiratory arrest o Lacerations needing
o Severe trauma sutures
o Severe burns o Sprains/strains
o Active severe o UTI
hemorrhage o Minor burns
o Acute myocardial o Mild pain
infarction ESI Level 5: Non-Urgent
ESI Level 2: Emergent • Characteristics:
• Characteristics: o No immediate attention
o Potentially life- required
threatening conditions o No life-threatening
o Unstable patients conditions
o Risk of rapid o Can wait extended
deterioration period
o Must be seen within 10 o No resources needed
minutes • Examples:
• Examples: o Cold symptoms
o Chest pain with o Work notes
suspected ACS o Medication refills
o Asthma exacerbation o Suture removal
o Moderate trauma
o Stroke-like symptoms
ESI Level 3: Urgent Key Components of ESI:
• Characteristics: • Severity of Illness or Injury:
o Stable vital signs Determines how serious the
o Require prompt patient's condition is.
assessment • Need for Resources: Takes into
o Not immediately life- account the number of
threatening resources (tests, procedures,
o Seen within 30 minutes imaging, consultations) the
o Require 2+ resources patient will require. Higher
• Examples: levels may require more
o Abdominal pain resources.
• Decision Tree: A set of criteria CANADIAN TRIAGE AND
that helps assess whether the ACUITY SCALE (CTAS)
patient's condition fits into one
of the five categories based on
their clinical presentation and
the resources they are
expected to need.
Advantages of ESI:
• Efficiency: Helps ED staff
quickly assess and prioritize
patients based on the severity
of their condition.
• Consistency: Standardizes
triage practices across
different emergency
departments.
• Flexibility: Can be adapted to
different ED settings and
patient volumes.
The ESI system improves patient flow
in busy emergency departments,
ensuring that those in the most critical START Triage (Simple Triage and
need of care receive it promptly Rapid Treatment)
while those with less severe conditions
wait in an appropriate timeframe. The START triage system is often
used in mass casualty situations
and disasters. It helps first
responders quickly assess and
categorize patients into four
groups:
• Red (Immediate): Life-
threatening conditions
requiring immediate care (e.g.,
severe bleeding, airway
obstruction).
• Yellow (Delayed): Serious but
not immediately life-
threatening conditions that
can wait for treatment (e.g.,
broken limbs, burns).
• Green (Minor): Patients with EMERGENCY CARE
minor injuries who can be
treated later (e.g., abrasions,
minor cuts).
• Black (Deceased/Expectant):
Patients who are deceased or
have no chance of survival
due to the severity of their
injuries (e.g., massive head
trauma).
TYPES OF SURVEY AND
ASSESSMENT
PRIMARY SURVEY
- To determine life threatening
conditions
A (Airway) – position patient,
open airway, remove visible
foreign materials (finger
sweep) or vomitus
B (Breathing) – look for chest
rise, listen for air coming out
from mouth or nose, feel for the
flow of air Circulation:
C (Circulation) – palpate
carotid artery (adult and
children), brachial artery
(infants)
D (Disability) – Assess Level of
Consciousness, AVPU: Alert,
Responsiveness to Voice,
Response to Pain and
Unresponsive/Unconsciousness
and Glasgow Coma Scale
GCS SECONDARY SURVEY
Eye: - After the primary survey is
4 - Spontaneous completed, perform a more
3 - Voice detailed secondary survey,
2 - Pain which includes a head-to-toe
1 - None assessment. This part of the
examination identifies all
Verbal: injuries sustained by the
5 - Normal orientation patient. At this time, a care
4 - Disoriented conversation plan is developed and
3 - Words but incoherent diagnostic tests are ordered
2 - No words only sound using EFGHI approach:
1 - None
- E - exposure and environmental
Motor: control
6 - Normalize
5 - Localizes pain 4 - Withdraws - Once the patient is exposed
to pain for full body assessment, their privacy
3 - Decorticate posture needs to be respected
2 - Decerebrate posture by providing a gown and blanket.
1 - None
- F - full set of Vital Signs
Assessing Level of LOC's (AVPU scale)
Consciousness: Heart rate
Respiratory rate
Primary Survey: (AVPU) Eye: Pupils equally rounded
and reactive to light and
Alert - awake and alert and accommodation (PERRLA)
needs no stimulus to respond to Skin
the environment
F - five interventions
Verbal - requires a verbal
stimulus to elicit a response § ECG
§ Pulse Oximeter
Pain - requires a painful § Indwelling catheter
stimulus to evoke a response (contraindicated in
pelvic trauma or
Unresponsive - unresponsive to suspicion of urethral
applied stimulus tear)
§ NG Tube inserted to
Provide gastric
decompression
§ Diagnostic and lab ED nurse may also use the
tests SAMPLE approach:
§ Facilitate Family
Process and Presence - Symptoms
pt’s. chief complaint
G - give comfort measures
- For many patients in the - Allergy
emergency type of allergies and allergic
department, levels of reactions
pain may be quite high.
- Medication history
H - history and head to toe prescribe, OTC drugs,
assessment herbal meds, etc.
*if trauma, start with head-to-
toe DCAP-BTLS - Past health history
previous illness and recent
v Deformities illness
v Contusions - Last meal
last oral intake
v Abrasions
- Events/Environment
v Punctures/Penetrations preceding illness or injury
events prior to injury
v Burns
v Tenderness PAIN ASSESSMENT
- You can also use OPQRST
v Lacerations
ü Onset - was the onset sudden
v Swelling or gradual?
ü Provokes/Palliates - what
I - Initiate monitoring devices makes it worse? better?
(ECG, Pulse oximeter, Urinary ü Quality – describe the pain,
Cath) sharp vs dull; constant vs
erratic
ü Radiates - does the sensation
move anywhere?
ü Severity - pain scale
ü Time - how long has it been
going on?
ALWAYS REMEMBER!!!
● Vitals Are Your Safety Net.
● Less Urgent and Non – Urgent
patients have NORMAL vital
signs.
● Abnormal vital signs are at
least URGENT.
● Triage is a dynamic process –
depending on pt’s. status &
condition
● A patient's condition may
improve or deteriorate during
the waiting for treatment.
● Reassessment, Reassessment,
Reassessment
