Emergency Nursing
Emergency Nursing
Emergency Nursing
Emergency Nursing: A specialty, because it is care given in a phase when a diagnosis has not been made and
the cause of the problem is not yet known.
Qualifications of an ER nurse:
• A BSN graduate and holder of a current license to practice nursing in the Philippines.
• Has had specialized education, training, and experience to gain expertise in assessing and identifying
patient’s health care problems in crisis situations.
Disaster – is a catastrophe which may be natural in origin or manmade, whether produced accidentally or
by design.
Stages of Disaster:
1. Threat Stage – when situation has a potential of creating crisis but does not show actual condition of peril
2. Warning Stage – it is more specific than the stage of threat and almost assures the reality of disaster
3. Impact – when the disaster is manifested full-blown
4. Recovery – when the assessment of the disaster effects is made, the injured are rescued, and rehabilitation
of people and their lives is begun.
Types of Disaster:
A. NATURAL
• FLOODS
• EARTHQUAKES
• STORMS
• TORNADOES / HURICANE
• EXTREME HEAT OR COLDNESS
• BUSH FIRES
• EPIDEMICS
B. MANMADE
• STRIKES
• RIOTS
• MASS SHOOTINGS
• HOSTAGE TAKING
• TERRORISM
• DEMONSTRATIONS
C. TECHNICAL
• VEHICULAR ACCIDENTS
• MAJOR INDUSTRIAL ACCIDENT
• BUILDING COLLAPSE
• HAZARDOUS CHEMICAL INCIDENTS
• FIRE INCIDENTS
Triage:
• Comes from French word “trier” meaning “to sort”
• Used to sort patients into groups based on:
– severity of their health problems
– immediacy with which these problems must be treated
• Classification of clients presenting to the ER for the purpose of prioritizing treatment
• Looks at medical needs and urgency of each individual patient
• Sorting based on limited data acquisition
• Also must consider resource availability
Categories of Triage:
1. Emergent – those conditions that require immediate care and intervention, increased risk of mortality (death) or
threat to life, limb, or vision.
2. Urgent – those conditions that require care ASAP, generally within 1 hour and have the potential for causing
deterioration of health state if not treated immediately.
3. Non-urgent – those conditions that require routine care that can be delayed for greater than 2 hours without the
possibility of deterioration
Coding of Triage
1. Emergent: Red, Priority I: life, limb, eye threatening that needs immediate attention, monitoring is continuous.
• Chest pain
• Cardiac arrest
• Severe respiratory distress
• Chemicals in eye
• Limb amputation
• Trauma
• Acute neurologic deficits
2. Urgent: Yellow, Priority II: needs treatment in 20 minutes to 2 hours, monitoring is every 30-60 minutes.
• Fever more than 40C (104F)
• diastolic BP more than 130mmHg
• kidney stones
• simple fracture
• abdominal pain
• asthma without respiratory distress
3. Non-urgent: Green, Priority III: can wait hours or days, monitoring is every 1-2 hours.
• Sprain
• Minor laceration
• Cold symptoms
• Rash
• Simple headache
4. Dead: Black (sometimes still with life signs but injuries are incompatible with survival)
Priorities of Treatment:
1. First Priority – individuals needing immediate attention to save life
• Any wound interfering with airway or causing airway obstruction.
• Sucking chest wounds, tension pneumothorax and maxillo-facial wounds in which asphyxia is present
or an impending threat.
• Any wound requiring immediate pressure for bleeding
• Shock due to major hemorrhage, to wounds of any organ systems, fractures, etc.
3. Third Priority – patients who require surgery but can tolerate a delay
• Spinal injuries in which decompression is required
• Lesser fracture & dislocations
• Minor injuries of the eye
• Soft tissue wounds in which debridement is necessary, but in which muscle damage is less than major
• Maxillo-facial injuries without asphyxia
Components of ER Nursing:
1. Establish Priorities: by using triage and accurate assessment.
2. Formulate Nursing Diagnoses
3. Plan/Implement
4. Documentation
B – BREATHING
a. Provide adequate ventilation, employing resuscitation measures when necessary
b. Application of oxygen via mask or bag-valve mask device
c. Assisting in chest tube insertion or endotracheal intubation
d. –Covering of open chest wound with occlusive dressing
C – CIRCULATION
a. CPR
b. Evaluate and restore cardiac output by:
controlling hemorrhage
preventing and treating shock
maintaining and restoring effective circulation
D – DISABILITY
a. Deformity-Open Wound-Tenderness-Swelling (DOTS)
b. Determine neurologic disability by completing a brief neurological assessment
c. Determine baseline functioning, potential life threatening complications.
d. Check LOC using GCS or RLS
1. Neurologic Assessment
1. Level of consciousness
2. Orientation to person, place, time, and event
3. Reaction Level Scale (RLS)
1 - Alert, fully conscious
2 - Drowsy, slightly confused
3 - Very drowsy, very confused, arousable to pain
4 - Unconscious, localizes
5 - Unconscious, withdraws
6 - Unconscious, decorticate
7 - Unconscious, decerebrate
8 - No reaction