EMERGENCY NURSING  Primary assessment – rapid initial

assessment while simultaneously

 The practice of episodic, primary, critical and intervening
acute nursing care of clients of all ages who
experience physical, emotional, or  A = airway with C-spine immobilization
psychological alterations in health; may be
 Ability to speak, foreign body, chest
given in a variety of practice settings
expansion
 Observe for possible causes
TRIAGE
 Prioritizing treatment Interventions:
 Requires brief, thorough interview
and assessment o Chin lift/ jaw thrust
o Suctioning
 Three Categories: o Intubation
 Emergent – Increased risk of mortality o Cricothyroidotomy
 Major burns, cardiac arrest, chest or tracheotomy
pain, respiratory distress, major blunt
B = Breathing
or penetrating trauma or hemorrhage
secondary to ectopic pregnancy Abnormal findings:

 2. Urgent – ASAP within 1 hour; Apnea

potential for causing deterioration of
Weak, shallow or labored respirations
health state
Fever of >39C for infants <3 mos, Absent breath sounds
abdominal pain, stable fractures,
headache, lacerations with controlled Unequal chest expansion
bleeding or dehydration
Retractions

 3. Non-urgent – require routine care; Tracheal deviation

can be delayed >2hrs without the
possibility of deterioration
DISASTER MANAGEMENT
 Community wide, hospital wide or
emergency department plan to
handle mass casualty incidents that
may occur at any time
 Coordinated planning
 Planning, mock drills and
refinement of plan
ASSESSMENT OF THE CLIENT PRESENTING TO THE ER
 Distended
neck veins
 Open chest
wound
 SC
emphysema
Possible Interventions:
 O2 by mask
or bag valve mask
 Assist with
chest tube insertion or intubation
 Covering of
open chest wound
 Use pressure
dressing over flail segment of the ribs
Secondary Assessment – head-to-toe assessment;
cervical immobilization; continues assessment of
hemodynamic and oxygenation status
o F = Fahrenheit; prevent heat loss

o G = Get vital signs (other assessment

aids, lab studies, toxicology)
 C =
Circulation/ Controlled Hemorrhage o H = History and head-to-toe
assessment
Indications of
o Head and face
decreased circulation:
 Bradycardia o Neck
or tachycardia
 Hypotension o Chest
 Cool, pale and
o Abdomen and flanks
diaphoretic skin
 Obvious o Pelvis and perineum
uncontrolled external bleeding
 Decreased o Extremities
LOC
o Posterior surface
Possible
Interventions:
AIRWAY OBSTRUCTION
 Direct
pressure  Etiology and Pathophysiology
 IV access and
fluid volume replacement  Trauma
 CPR  Mechanical obstruction
 Pericardiocen  allergy, infection, chemical
tesis irritants or burns
 Blood  medical and neurological
transfusion conditions

 Assessment:
 D = Disability
 Inability to speak, breathe or
 Brief neurological assessment (Glasgow
cough
Coma Scale)
 Stridor, wheezing, choking,
 E = Expose gagging or drooling à partial
 Late: Cyanosis, SOB, altered
mental status, bradycardia,
hypotension and cardiac
arrest
  Absent breath sounds or tion
adventitious breath sounds methods
humidified
 Diagnostic and Lab tests
O2
Radiographic studies
of the neck Medication therapy:

ABG  Antibiotics

Management:  bronchodila
tors
Conscious à attempt
to clear own AW  sedation
and muscle
Suctioning
relaxants
Unconcsious à Chin lift, intubations,
cricothoratomy or tracheostomy

TENSION PNEUMOTHORAX

o Air
enters
Nursing Diagnoses:
the
Ineffective AW pleural
clearance space
through
Ineffective breathings
a tear
pattern
during
inspiratio
n and
Planning and Implementation:
cannot
Maintain escape
AW patency during
keep expiratio
suction n
equipment
 Etiology and Pathophysiology
available
C-spine  Blunt or penetrating
immobiliza trauma
tion
 ruptured bleb or positive
alternative
pressure mechanical
communica
ventilation
  “one way valve effect” à  P
hyperinflation, lung collapse, r
increased mediastinal pressure e
and shift towards the p
a
uninjured part à compression
r
of vena cava
e
 A f
ss o
r
es
n
s
e
m
e
e dl
nt e
: t
h
 Labored respirations, o
dyspnea, tachypnea, hypoxia, r
absent breath sounds, tracheal a
deviation away from the injured c
site, distended neck veins, o
decreased CO st
o
 Diagnostics: PA-CXR m
y
 M
o
a
r
n
c
ag
h
e
e
m
st
e
t
nt
u
:
b
 H
e
ig
pl
h
a
fl
c
o
e
w
m
O
e
2
 n  I
t m
 N p
ur ai
si r
ng e
Di d
ag g
n a
os s
es e
 In x
e c
ff h
e a
c n
ti g
v e
e  Pl
b a
r n
e ni
a ng
t a
hi n
n d
g I
p m
a pl
tt e
e m
r e
n nt
 D a
e ti
cr o
e ns
a  S
s u
e p
d pl
C e
O m
 e o
n m
t y
al  m
O o
2 ni
 A t
ss o
is r
t  E
w n
it c
h o
c u
h r
e a
st g
t e
u d
b e
e e
in p
s b
e r
r e
ti a
o t
n h
o s
r  C
n h
e a
e n
dl g
e e
t p
h o
o si
r ti
a o
c n
o e
st v
 e IV access
r Pulse oximetry and ABGs
y Pain management
2 Nursing Diagnoses:
h  Ineffective Breathing Pattern
o  Impaired Gas exchange
u  Pain
rs  Impaired Tissue integrity
 M  Planning and Implementations
e  O2
di  IV access
ca  Pain management
ti  Splinting
o  Medications: Opioid analgesics, Nerve blocks
n: or PCA
A
n
al
ge
si
cs

UNCONTROLLED HEMORRHAGE
FLAIL CHEST  Etiology and Pathophysiology
Fracture of 3 or more contiguous ribs in 2 or  Blunt or
more places penetrating
trauma
Etiology and Pathophysiology:
 GI or GU
Blunt trauma bleeding or
Increase intrathoracic pressure à flail hemoptysis
segment drawn inward and bulges outward  Decreased
tissue
Assessment: perfusion à
hypoxia à
Dyspnea, chest wall pain, ecchymosis,
vasoconstrictio
hypoxia, pain on inspiration, palpable SC
n and shunting
emphysema
of blood to
Diagnosis: CXR, ABG
vital organs
Management:  (+) SNS à ADH
à RAAS
O2
  Metabolic of bleeding;
acidosis, MOSF surgical
 IVF
 Assessment: resuscitation
 cool, clammy, pale skin  Blood
 delayed capillary refill time replacement
 weak, rapid pulses therapy
 hypotension  Monitor
 rapid shallow respirations cardiac
 restless, anxious or decreased LOC rhythm, v/s,
 cardiac dysrhythmias CVP, mental
 Decreased UO status and UO

 Diagnosis:  Nursing Diagnosis:

o Bleeding from thoracostomy Impaired Tissue
o Abdominal or pelvic CT scan Perfusion
o Endoscopy Deficient Fluid
o Angiography Volume
Decreased Cardiac
o Extremity radiographs
Output
o Hgb and hct
 Planning and
o Elevated serum lactate
Implementation
o ABGs à metabolic acidosis
O2
o Baseline coagulation studies
Control external bleeding
o Others: Electrolytes
IV access for crystallioid solutions
Draw blood specimens
Insert indwelling catheter and NGT
Perform and document continuous serial
assessment of hemodynamic parameters
keep client warm
 Medications:
Crystalloids and
blood products
Sodium
bicarbonate
 Management: Vasopressors
 Patent AW (Dopamine)
 C-spine 
immobilization MOTOR VEHICULAR ACCIDENTS; BLUNT
 Direct pressure TRAUMA
and find
hidden source Etiology and Pathophysiology:
 Three types of Forces:  NGT and indwelling
o Acceleration/ deceleration forces urinary catheter
o Compression forces insertion
o Shearing forces  Radiological
procedures
 Type of impact, speed, point of impact,  ECG
restraint systems, clients pre-existing  Positioning,
conditions splinting, ice and
 Fractures, lacerations, contusions, rupture or elevation
tearing  prepare for surgery

Assessment: *Planning and Implementations:

 Clinical  AW management
Manifestations:  C-spine
 Hypovolemia immobilization
 Blunt trauma  observe breathing
to the head, neck and SC  assist with chest
 Blunt tube insertion,
abdominal trauma monitor for drainage
 Blunt trauma  assist with
to the extremities diagnostic
procedures
 Diagnosis:  psychological
o X-ray, CT scans, UTZ and MRI support
o Diagnostic peritoneal lavage  Medications:
o ECG  NSS or LR
 Tetanus
Lab tests: CBC, electrolytes, Urinalysis, serum immunization
amylase and lactate, liver enzymes, cardiac  antibiotics
enzymes, clotting studies, ABGs, toxicology  analgesics
 vasopressors

 Management: PENETRATING INJURIES

 Assess and stabilize
 Low velocity missiles – (+)
A B, C
damage only along the path of the weapon
 O2
 Modified  High velocity, high-energy
Trendelenburg missiles – also damages surrounding tissues
position
 Insert 2 large bore IV  Etiology and
lines Pathophysiology:

 Low velocity
 Weapon used, structure of the weapon, Monitor v/s; administration of fluids and
position of the victim and position of attacker blood products
Gender of attacker sterile dressing changes, monitor for
High Velocity, high kinetic energy missiles drainage, redness and signs of healing;
Caliber, type of missile, distance from victim, antibiotics
trajectory into the body Pain management
Injuries Keep client and family informed
Medications:
Assessment: Tetanus immunization
Clinical manifestations: antibiotics
analgesics
Open wound

Symptoms of shock
HYPOTHERMIA
Diagnostics:

Direct assessment Core body temperature is 36C or less

Radiographic studies Etiology and Pathophysiology:

Ultrasound Decrease in BMR

CBC, electrolytes
Cardiac and hepatic enzymes, amylase
ABG
Management:
Stabilization A, B, C
Placement of chest tube
Surgical exploration and repair of heart
Surgical resection of bowel or GIT
Surgical intervention for bladder rupture
Soft tissues à monitor for complications
Firm tissues à surgical intervention or
amputation
Decreased circulation à acidosis à death
Assessment:
Clinical Manifestations
Core body temperature 36C or less
Mild (33-36C) à lethargic, shivering, mildly
confused, ataxic, diminished fine motor skills
Moderate (28-32C) à shivering will cease,
coma, bradycardia and bradypnea, pupils
dilate, ventricular dysrhythmia
Severe ( <28C) à depressed respiratory,
cardiovascular and neurologic function,
appears dead, ECG asystole, muscle rigidity
Diagnostics: ABGs à acidosis
Management:

Stabilize AW and breathing; O2, mechanical

Planning and Implementation: ventilation
Observe cardiac monitor
AW management; intubation and mechanical
Faster rewarming
ventilation
CPR and defibrillation
Splinting area and coughing and deep
breathing Planning and Implementation:
 Establish AW and breathing CBC, electrolytes
Initiate cardiac monitoring BUN, crea and glucose
assist with rewarming Urinalysis, myoglobinuria
Monitor UO
Assess pulmonary status Management:
Monitor ABG and electrolytes Remove from cold environment before
Keep client and family informed thawing
Immerse areas in warm water
area should not be rubbed
Medication: Monitor body temperature
Dextrose 50% 50 ml IV After thawing, gently wrap the extremity and
Amiodarone 300 mg IV push elevate it
150 mg every 3-5 mins Blisters may or may not be debrided
Maximum of 2.2 grams over 24 hrs Amputation will not be considered
IV drip at 15 mg/ min Planning and Implementations:
Assist with thawing
Remind client not to rub the areas
antibiotics and sterile bulky dressings
Pain management

Medications:
Aloe vera (topical)
Tetanus prophylaxis
Antibiotics
Parenteral and oral analgesics
FROST BITE
Etiology and Pathophysiology:

Loss of body heat à vasoconstriction à tissue

ischemia HEAT EXHAUSTION
Tissue freezes à (+) ice crystals à edema and Vasomotor collapse
mechanical damage to the cells
Etiology and Pathophysiology:
(+) Clumping of platelets and erythrocytes
Dehydration à loss of salt and water
Assessment:
Results from exercising vigorously in hot weather
Clinical Manifestations:
Pain, loss of sensation and paresthesia  Predisposing Factors:
Edematous, red, blistered, white, hard and cold
Advanced age
to touch or necrotic
Stinging, burning or aching Use of diuretics

Diagnostic and Lab findings: Preexisting fluid disorder

Clinical findings Assessment:

 Clinical Manifestations: Preexisting illnesses
N/V, headache, light headedness, malaise or
myalgia Obesity
Pale, warm and moist skin Medications:
Body temp from 39-41C Phenothiazines,
Impaired judgment and slightly confused tricyclic anti-
Diagnostics: depressants,
diuretics, and beta
Electrolytes à decreased K+ blockers
Decreased Na+
Person progressively loses fluid through evaporation à
Increased hct
unable to produce enough perspiration

Increased body temp à cardiac collapse

Brain injury à NS damage

Management:
Diagnosis:
Rest in cool, shaded area
CBC
Tepid water and direct fans toward client
Electrolytes à Hypernatremia, hypokalemia and
F/E replacement orally and IV hypoglycemia

Planning and Implementations: LFT à liver failure, rhabdomyolysis

Prevention of further F/E loss PTT and PT à clotting abnormalities

Increasing body temp ABGs à metabolic acidosis

F/E replacement Management:

TSB Cooling measures

Prevent shivering Prevent shivering

Medications: F/E solutions Cardiac monitoring

HEAT STROKE (HYPERTHERMIA) Ice water gastric and peritoneal lavage

Extremely elevated body temp
Planning and Implementation:
Etiology and Pathophysiology:
A, B, C
Most serious heat related emergency
Use NSS; do not use LR
Predisposing Factors:
Insert urinary catheter
Elderly
Use cooling measures
High humidity and temperature
Monitor cardiac rhythm ABGs à acidosis

Prevent shivering, acidosis and cerebral edema CBC à hemodilution

Medications: Na+ à elevated or decreased

Chlorpromazine (Thorazine) CXR à bilateral infiltrate

Benzodiazepines Management:

Mannitol AW, breathing

Methylprednisolone ET intubation and mechanical ventilation

Frequent suctioning and O2

DROWNING AND NEAR DROWNING LR or NSS

Description: Inset urinary catheter

Drowning – death caused by asphyxia and Correct hypoxia, and acidosis

aspiration
Near drowning – risk of death occurring CPR
within 24 hrs after submersion Antibiotics
Etiology and Pathophysiology Medications
Asphyxiation (suffocation) Epinephrine 1mg IV push
Water enters lungs à removal of surfactant à
increase alveolar surface tension à decrease Lidocaine 1-1.5 mg/kg IV push
O2 perfusion
Atropine 1mg IVP
Chemical pneumonitis
Hypertonic state à pulmonary edema Sodium bicarbonate
Alveolar ventilation decreases à cardiac arrest
Near drowning does not expire immediately Steroids

Assessment: Bronchodilators

Clinical Manifestations: Isoproterenol

Dyspnea, hypoxia, wheezing, crackles, Antibiotics

rhonchi. Cough, with pink frothy sputum

Tachycardia, cyanosis

Mental confusion, seizures

Cardiac or respiratory arrest

Diagnosis: