Lippincott Manual of Nursing Practice, 8 th Ed Emergent Conditions
BASIC APPROACH TO EMERGENCY CARE
Emergency care can be defined as the episodic and crisis-oriented care
provided to patients with serious or potentially life-threatening injuries
or illnesses. The philosophy of emergency care includes the concept
that an emergency is whatever the patient or family considers it to be.
See Standards of Care Guidelines.
Emergency Assessment
A systematic approach to the assessment of an emergency patient is
essential. Usually, the most dramatic injury is not the most serious. The
primary and secondary surveys provide the emergency nurse with a
methodical approach to help identify and prioritize patient needs.
Primary Assessment
The initial, rapid, ABCD (airway, breathing, and circulation, as well as
neurologic disability resulting from spinal cord or head injuries)
assessment of the patient is meant to identify life-threatening
problems. If conditions are identified that present an immediate threat
to life, appropriate interventions are required before proceeding to the
secondary assessment.
 A Airway: Does the patient have an open airway? Is the patient
able to speak? Check for airway obstructions such as loose
teeth, foreign objects, bleeding, vomitus or other secretions.
Immediately treat anything that compromises the airway.
 B Breathing: Is the patient breathing? Assess for equal rise and
fall of the chest (check for bilateral breath sounds), respiratory
rate and pattern, skin color, use of accessory muscles, integrity
of the chest wall, and position of the trachea. All major trauma
patients require supplemental oxygen via a nonrebreather
mask.
 C Circulation: Is circulation in immediate jeopardy? Can you
palpate a central pulse? What is the quality (strong, weak,
slow, rapid)? Is the skin warm and dry? Is the skin color
normal? Obtain a blood pressure (in both arms if chest trauma
is suspected).
 D Disability: Assess level of consciousness and pupils (a more
complete neurologic survey will be completed in the
secondary survey). Assess level of consciousness using the
AVPU scale:
o A Is the patient alert?
o V Does the patient respond to voice?
o P Does the patient respond to painful stimulus?
o U The patient is unresponsive even to painful
stimulus.
Secondary Assessment
The secondary assessment is a brief, but thorough, systematic
assessment designed to identify all injuries. The steps include
Expose/environmental control, Full set of vital signs/Five
interventions/Facilitate family presence, and Give comfort measures.
 Expose/environmental control: It is necessary to remove the
patient's clothing in order to identify all injuries. You must
then prevent heat loss by using warm blankets, overhead
warmers, and warmed I.V. fluids.
 Full set of vital signs/five interventions/facilitate family
presence:
o Obtain a full set of vital signs including blood
pressure, heart rate, respiratory rate, and
temperature. As stated previously, obtain blood
pressure in both arms if chest trauma is suspected.
o Five interventions:
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 Pulse oximetry to measure the oxygen
saturation
 Indwelling urinary catheter (do not insert if
you note blood at the meatus, blood in the
scrotum, or if you suspect a pelvic fracture)
 Gastric tube (if there is evidence of facial
fractures, insert the tube orally)
 Laboratory studies frequently include type
and crossmatching, hemoglobin and
hematocrit, urine drug screen, blood
alcohol, electrolytes, prothrombin time (PT)
and partial thromboplastin time, and
pregnancy test if applicable
o Facilitate family presence: It is important to assess
the family's needs. If any member of the family
wishes to be present during the resuscitation, it is
imperative to assign a staff member to that person to
explain what is being done and offer support.
 Give comfort measures: These include verbal reassurances as
well as pain management as appropriate. Do not forget to give
comfort measures to the family during the resuscitation
process.
Standards Of Care Guidelines
Emergency Assessment and Intervention
When a patient presents with a potentially life-threatening condition,
proceed swiftly with the following:
 Remove the patient from potential source of danger, such as
live electrical current, water, or fire.
 Determine whether patient is conscious.
 Assess airway, breathing, and circulation in systematic
manner.
 Assess pupillary reaction and level of responsiveness to voice
or touch as indicated.
 If the patient is unconscious or has sustained a significant head
injury, assume there is a spinal cord injury and ensure proper
handling.
 Undress the patient to assess for wounds and skin lesions as
indicated.
 Immediate intervention is needed for such conditions as
compromised airway, respiratory arrest, compromised
respirations, cardiac arrest, and profuse bleeding. Provide
emergency airway management, cardiopulmonary
resuscitation, and measures to control hemorrhage as needed.
 Call for help as soon as possible.
 Assist with transport and further assessment and care as
indicated.
History
 Obtain prehospital information from emergency personnel,
patient, family, or bystanders using the mnemonic MIVT
o M Mechanism of injury: It is helpful to understand
the mechanism of injury to anticipate probable
injuries. It is particularly helpful in motor vehicle
accidents to know such information as external and
internal damage to the car and the period of time
elapsed before the patient received medical
attention.
o I Injuries sustained or suspected: Ask prehospital
personnel to list any injuries that they have
identified.
o V Vital signs: What were the prehospital vital signs?
Lippincott Manual of Nursing Practice, 8 th Ed Emergent Conditions mikEL rlh mantong
o T Treatment: What treatment did the patient receive
before arriving at the hospital and what was his TRIAGE
response to those interventions?
Triage is a French verb meaning to sort. Most patients entering an
 If the patient is conscious, it is essential to ask him what
emergency department (ED) are greeted by a triage nurse, who will
happened. How did the accident occur? Why did it happen? A
perform a brief evaluation of the patient to determine a level of acuity
fall, for example, may not be a simple fall perhaps the patient
or priority of care. Thus, the role of the triage nurse is to make acuity
blacked out and then fell.
determinations and set priorities.
 Obtain past medical history from the patient or a family
member or friend, including age, medical/surgical history, Priorities of Care and Triage Categories
current medications, use of any illicit drugs, allergies, last
menstrual period, last meal, and last tetanus shot. Standardized triage categories are usually developed within each ED.
Most common triage systems consist of five levels of acuity.
Head-to-Toe Assessment
Triage Level I Resuscitation
The head-to-toe assessment begins with assessment of the patient's
 Conditions requiring immediate nursing and physician
general appearance, including body position or any guarding or
assessment. Any delay in treatment is potentially life- or limb-
posturing. Work from the head down, systematically assessing the
threatening.
patient one body area at a time.
 Includes conditions such as:
 Head and face
o Airway compromise.
o Inspect for any lacerations, abrasions, contusions, o Multisystem
o Cardiac arrest.
avulsions, puncture wounds, impaled objects, trauma.
o Severe shock.
ecchymosis, or edema. o Altered LOC
o Palpate for crepitus, crackling, or bony deformities. o Cervical spine injury.
(unconsciousness)
 Chest o Eclampsia.
o Inspect for breathing effectiveness, paradoxical chest Triage Level II - Emergent
wall movement, disruptions in chest wall integrity.
o Auscultate for bilateral breath sounds and  NxAx and physician Ax within 15 minutes of arrival.
adventitious breath sounds.  Conditions include:
o Head injuries. o Abdominal
o Palpate for bony crepitus or deformities.
o Severe trauma. pain in patients older
 Abdomen/flanks than age 50.
o Inspect for lacerations, abrasions, contusions, o Lethargy or agitation.
o Vomiting
avulsions, puncture wounds, impaled objects, o Conscious overdose.
and diarrhea with
ecchymosis, edema, scars, eviscerations, or o Severe allergic reaction.
dehydration.
distention. o Chemical exposure to eyes.
o Fever in
o Auscultate for the presence of bowel sounds. o Chest pain.
infants younger than 3
o Palpate for rigidity, guarding, masses, or areas of o Back pain.
months.
tenderness. o GI bleed with unstable VS.
o Acute
 Pelvis/perineum o Stroke with deficit.
psychotic episode
o Inspect for lacerations, abrasions, contusions, o Severe asthma.
o Severe
avulsions, puncture wounds, impaled objects, o Any sexual assault.
headache.
ecchymosis, edema, or scars. Look for blood at the o Any pain
Triage Level III Urgent
urinary meatus. Look for priapism (which could greater than 7 on a scale
indicate spinal cord injury).  Conditions requiring nursing and physician
of 10. assessment within
o Palpate for pelvic instability and anal sphincter tone. 30 minutes of arrival. o Any
 Extremities  Conditions include: oneonate age 7 Abuse days oror
o Inspect skin color and temperature. Look for signs of o Alert head injury with vomiting
younger.
neglect.
injury and bleeding. Does the patient have o Mild to moderate asthma. o GI bleed
movement and sensation of all extremities? o Moderate trauma. with stable VS.
o Palpate peripheral pulses, any bony crepitus, or areas
Triage Level IV Less Urgent o History of
of tenderness.
seizure, alert on arrival.
 Posterior surfaces utilizing help, logroll the patient in order to  Conditions requiring nursing and physician assessment within
o Inspect for possible injuries. one hour.
o Palpate the vertebral column and all areas for  Conditions include: o Alert head
tenderness. o Earache. injury without vomiting.
o o
Minor allergic reaction. Minor
Focused Assessment o Corneal foreign body. trauma.
Any injuries that were identified during the primary and secondary o Chronic back pain. o Vomiting
surveys require a detailed assessment, which will typically include a and diarrhea in patient
Triage Level V Nonurgent older than age 2 without
team approach and radiographic studies.
 Conditions requiring nursing and evidence
physicianofassessment
dehydration.within
two hours.
 Conditions include: o Minor
o Minor trauma, not acute. symptoms.
o Chronic
abdominal pain.
Lippincott Manual of Nursing Practice, 8 th Ed Emergent Conditions
o Sore throat.
Approach to the Family
PSYCHOLOGICAL CONSIDERATIONS
Trauma is an insult to physiologic and psychological
homeostasis; it requires physiologic and psychological healing.
Approach to the Patient
 Understand and accept the basic anxieties of the
acutely traumatized patient. Be aware of the patient's
fear of death, mutilation, and isolation.
o Personalize the situation as much as possible.
Speak, react, and respond in a warm manner.
o Give explanations on a level that the patient
can grasp. An informed patient can cope with
psychological/physiologic stress in a more
positive manner.
o Accept the rights of the patient and family to
have and display their own feelings.
o Maintain a calm and reassuring manner helps
the emotionally distressed patient or family
to mobilize their psychological resources.
 Understand and support the patient's feelings
concerning loss of control (emotional, physical, and
intellectual).
 Treat the unconscious patient as if conscious. Touch,
call by name, and explain every procedure that is
done. Avoid making negative comments about the
patient's condition.
o Orient the patient to person, time, and place
as soon as he or she is conscious; reinforce by
repeating this information.
o Bring the patient back to reality in a calm and
reassuring way.
o Encourage the family, when possible, to
orient the patient to reality.
 Be prepared to handle all aspects of acute trauma;
know what to expect and what to do. This alleviates
the nurse's anxieties and increases the patient's
confidence.
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 Inform the family where the patient is, and give as
much information as possible about the treatment he
or she is receiving.
 Consider allowing a family member to be present
during the resuscitation. Assign a staff person to the
family member to explain procedures and offer
comfort.
 Recognize the anxiety of the family and allow them to
talk about their feelings. Acknowledge expressions of
remorse, anger, guilt, and criticism.
 Allow the family to relive the events, actions, and
feelings preceding admission to the ED.
 Deal with reality as gently and quickly as possible;
avoid encouraging and supporting denial.
 Assist the family to cope with sudden and unexpected
death. Some helpful measures include the following:
o Take the family to a private place.
o Talk to all of the family together so they can
mourn together.
o Assure the family that everything possible
was done; inform them of the treatment
rendered.
o Avoid using euphemisms such as passed on.
Show the family that you care by touching,
offering coffee.
o Allow family to talk about the deceased
permits ventilation of feelings of loss.
Encourage family to talk about events
preceding admission to the ED.
o Encourage family to support each other and
to express emotions freely grief, loss, anger,
helplessness, tears, disbelief.
o Avoid volunteering unnecessary information
(eg, patient was drinking).
o Avoid giving sedation to family members may
mask or delay the grieving process, which is
necessary to achieve emotional equilibrium
and prevent prolonged depression.
o Be cognizant of cultural and religious beliefs
and needs.
o Encourage family members to view the body
if they wish to do so helps to integrate the
loss (cover mutilated areas).
 Go with family to see the body.
 Show acceptance of the body by
touching to give family permission to
touch and talk to the body.
 Spend a few minutes with the family,
listening to them.
 Encourage the ED staff to discuss among themselves
their reaction to the event to share intense feelings
for review and for group support.
Lippincott Manual of Nursing Practice, 8 th Ed Emergent Conditions mikEL rlh mantong

CARDIOPULMONARY RESUSCITATION AND

AIRWAY MANAGEMENT
Cardiopulmonary resuscitation (CPR) is a technique of basic
life support for the purpose of oxygenating the brain and
heart until appropriate, definitive medical treatment can
restore normal heart and ventilatory action. Management of
foreign-body airway obstruction or cricothyroidotomy may be
necessary to open the airway before CPR can be performed.

Cardiopulmonary Resuscitation
See Procedure Guidelines 35-1: Cardiopulmonary
Resuscitation.

Indications
 Cardiac arrest
o Ventricular fibrillation
o Ventricular tachycardia
o Asystole
o Pulseless electrical activity
 Respiratory arrest
o Drowning
o Stroke
o Foreign-body airway obstruction
o Smoke inhalation
o Drug overdose
o Electrocution/injury by lightning
o Suffocation
o Accident/injury
o Coma
o Epiglottitis

Assessment
 Immediate loss of consciousness
 Absence of breath sounds or air movement through
nose or mouth
 Absence of palpable carotid or femoral pulse;
pulselessness in large arteries

Complications
 Postresuscitation distress syndrome (secondary
derangements in multiple organs)
 Neurologic impairment, brain damage