SME NOTES
the patient will be admitted considered to be in
EMERGENCY NURSING DAY 1
Objectives:
• Describe emergency care as collaborative,
holistic approach that includes the patient, the
family ad significant others.
• Discuss priority emergency measures instituted
for the patient with an emergency condition.
• Identify the priorities of care for the patient
with multiple system injuries.
• Compare and contrast the emergency
management of patient with heat stroke,
frostbite and hypothermia.
• Specify the similarities and differences of the
emergency management of patients with
swallowed or inhaled poisons, skin
contamination, and food poisoning.
• Explain the emergency management of patients
with drug overdose, those with acute alcohol
intoxication, those who have been sexually
assaulted, and those who have been victims of
human trafficking.
• Differentiate between the emergency care of
patient who are overactive, those who are
violent, those who are depressed, and those
suicidal.
Accident and emergency, emergency ward,
emergency department or Casualty Department.
- Refers to care given with urgent and critical
needs
- Is a specialty within the field of professional
nursing focusing on the care of patients who
require prompt medical attention to avoid long
term disability or death?
- Specializing acute care who present without
prior appointments.
- Near into admission unit.
- If in critical case, they will be sent to the ICU
- Within 2 hours the patient will be stable
(standard) transported to the room of choice.
ER NURSE
- Specialized education, training experience and
expertise in ASSESSING and IDENTIFYING
patients’ health care problems in crisis
situations.
- Triage nursing/area – assess by an ER NURSE if
out-patient department.
- Establishes priorities (accomplish
interdependently = consult with or under the
direction of the physicians)
- Monitors and continuously assess the patient as
long as they are still in the emergency
department.
- Supports and attends to all the needs of patient
- Supervises allied health personnel (novice
nurses, student nurses)
- Educates within a time-limited, high-pressured
environment (from time to time even in the
very pressured environment)
Nursing interventions:
- Accomplish independently
- Are anticipated based on assessment data
- Work as a team in performing the highly
technical, hands-on skills required to care.
- They are very flexible.
ISSUES
- Demanding environment
a. Legal issues
b. Occupational health and safety risk
for ED staff
c. Providing holistic care
d. Nursing disasters
CONSENT
- To examine and treat is part of the ED record
- Unless he/she is unconscious or in a critical
condition and unstable to make decision = refer
to support system.
- It will be expired for about 24 hours. (If the
patient or family were not able to decide if the
family already agreed or not with the
procedure.
PRIVACY
- In every emergency department with medical
care will always have a PRIVACY POLICY (Federal
Law)
- Agreement
- Health insurance portability and accountability
act
 - “alias” and access to electronic health record is
limited.
- Limiting access to their room
- Not to receive phone calls, mails, flowers, other
gifts, or visitors.
LIMITING EXPOSURE OF RISK
- Due to the increasing numbers of people
infected.
- Use fitted with personal high efficiency
particulate air (HEPA) filter masks. (Droplets,
and other fluids)
Heavy breathing = wear masks
- Early identification and strict adherence to
transmission-based precaution is crucial.
PERPETUAL SETTING ER
- 12 rooms
- Bed 5,6, and 7 are for critical patients
- Each bed has its own bed side table and
- You are standing and working for 12 hours will
just walk forever.
- Each area has its own sink
- Attending 6 to 10 patients
VIOLENCE IN THE ED
- Due to substance abuse, injury, other
emergencies, SO are emotionally volatile
(unpredictable)
- It is very important to consider that safety is our
priority.
- Assigned security officers, installed silent alarm
systems or metal detectors.
HOW TO EMPLOY SAFE USE OF RESTRAINTS
- Strict standards regarding documentation
- Precautions
Supine patient in 4-point restraints on a stretcher.
One arm up on arm down
Head raised 30 degrees
- For prisoner, the hand/ankle restraint is never
released, and a guard is always present.
TO MONITOR THE PATIENT
TO MAKE SURE THE DIGNITY OF THE PATIENT
- A mask can be placed to prevent spitting or
biting
- Nonrestraint techniques should be tied when
possible
- Physical restraints for violent patients (cloth)
- Distance should be maintained
- Objects should not be left within reach
- Courses on safety
PUBLIC JAIL, will be admitted to a PRIVATE
HOSPITAL, CAN OFFER CARE PERO ONCE STABLE
TRANSFER THEM TO THE PUBLIC HOSPITAL.
PROVIDING HOLISTIC CARE
Patient/SO
- Overwhelmed by anxiety
- Experience is real and terrifying
- Mutilation
- Immobilization
- Other assaults
(Denial, remorse, guilt, grief, and reconciliation)
GOAL:
To reduce their Anxiety
To give effective and appropriate coping to our patient
and significant other = closed observation and pre plan.
PATIENT FOCUSED INTERVENTIONS
- Clinicians caring for the patient should act
confidently and competently to relieve anxiety
and promote a sense of security.
- Explanation should be given that the patient
can understand
- Human contact and reassuring words reduce
the panic of the person who is severely injured
or ill and aid in dispelling fear of the unknown.
- They need to receive the basic information from
time to time.
FAMILY FOCUSED INTERVENTIONS
- The family is kept informed about where the
patient is, how he or she is doing, and the care
that is being given.
- Encourage the family members to stay with the
patient. As much as possible 1-2 SO are allowed.
- Family presence during resuscitation is
permitted.
HELPING FAMILY MEMBERS COPE WITH SUDDEN DEATH
- Take the family to a private place
- Talk to the family together so that they can
grieve together and hear the information given
together.
- Reassure the family that everything possible
was done; inform them of the treatment
rendered.
- Avoid using euphemisms such as “passed on”.
Show the family that you care by touching,
offering coffee, water and the services of the
chaplain.
- Encourage the family members to grieve
together.
- Avoid giving sedation to family members
- Encourage the family to view the body if they
wish; this action helps to integrate the loss.
- Spend time with the family, listening to them
and identifying any needs that they may have
for which the nursing staff can be helpful.
- Allow family members to talk about the
deceased and what he or she meant.
- Encourage the family to talk about the events
preceding admission to the ED.
- Do not challenge initial feelings of anger or
denial
- Avoid volunteering unnecessary information
ANXIETY AND DENIAL
- Encouraged to recognize and talk about their
feelings of anxiety.
- Asking questions is encouraged
- Honest answers given at the level of the family’s
understanding must be provided.
- Although denial is an ego defense mechanism
that protects one from recognizing painful and
disturbing
REMORSE AND GUILT
- expressions of remorse and guilt are common,
with family members accusing themselves of
negligence or minor issues.
- Family members are urged to verbalize their
feelings to help them cope appropriately.
ANGER
- Expressions of anger, common in crisis
situations are a way of handling anxiety an fear
- Anger is frequently directed by the family of the
patient, but it is alsi often expressed toward the
physician, the nurse or admitting personnel.
- The therapeutic approach is to allow the anger
to be expressed and to assist the family
members to identify their feelings of
frustration.
GRIEF
- Is a complex emotional response to anticipated
or actual loss.
- The key nursing intervention is to help family
members work through
CARING FOR ER NURSE
- focus on the needs of the staff especially after
stressful and serious events.
- It is important to remember that all staff may
not be necessarily respond in the same way; an
event is stressful to one person may not be the
same to another person.
- Compassion fatigue.
EMERGENCY NURSING AND THE CONTINUUM OF CARE
Discharge planning – we should not forget the
verbal and writing instructions. Before discharge,
some patients require the different services.
Community and transitional services
Gerontology considerations – different
complications
Obesity consideration – explain everything.
PRINCIPLES
TRIAGE – French word “trier” meaning to sort into
groups.
- (In medical use) the assignment of degrees of
urgency to wounds or illnesses to decide the
order of treatment of a large illnesses to decide
the order of treatment of a large number of
patients or casualties.
- An advanced skill usually used in disasters and
mass casualty incidents.
ASSESSMENT – TRIAGE CATEGORIES
1. Emergency – those with emergency signs
require immediate emergency treatment.
 2. Priority – those with priority signs should be
given priority in que for rapid assessment and
treatment.
3. Non-urgent – those who have no emergency or
priority signs are non-urgent cases and can wait
their turn for assessment and treatment.
RED
- Patient requires immediate attentions
- Have a highest priority
- Suicide, via poisoning, hanging or self-induced
trauma.
Example: severe blood loss, overdose
Deadline: within 10 minutes
Category 3 - urgent
Example: head injury (conscious) breathing difficulties,
infection
Deadline: within 30 minutes
Category 4 – semi-urgent
Example: sprained ankle with possible fracture, eye
inflammation

Deadline: within one hour

YELLOW
Category 5 – non urgent
- Urgent
- Patient is stable at the moment and is not in any Example: cut not requiring stitches, common colds
immediate danger, but will require observation
Deadline: within 2 hours.
- Serious but not life threatening
- Passive suicidal ideation, command (Appropriate time to ask questions)
hallucinations.
- What were the circumstances
- Can be addressed within one hour
- What happened to the patient?
- Asked the location and the time of the injury
GREEN that occurs.
- Patient who will require medical treatment at - You ask when did the symptoms appear?
some point, once more critical injuries have - How did the patient get to the emergency
been treated. department?
- Non-urgent CANADIAN TRIAGE AND ACUITY SCALE
- Episodic in nature that can be addressed for 24
hours Level I – Resuscitation
- Drug refill for anti-depressants or anti-anxiety
Level II – Emergent
medications.
Level III – Urgent
BLACK Level IV – Less Urgent
- For those who are already decreased, or for Level V – Non-Urgent
patients whose injuries are so extensive that
they will be able to survive, given the level of ASSESS AND INTERVENE
care available.
Primary Survey
- Expectant, they already have a low chance of
survival. - Focuses on stabilizing life-threatening
conditions
TRIAGE USED IN PSH
- Follow the ABCDE
Category 1 – resuscitation - Employing resuscitation measures
- Evaluates and restore CO
Example: Heart Attack, major car accident - Determine neurological disability status
Deadline: immediate (seconds) - GCS and AVPU mnemonics

Category 2 – Emergency Secondary Survey

 - Complete health history
- Head-to-toe assessment
- Diagnostic and laboratory testing’s
- Insertion and application of monitoring devices
- Splinting of suspected fractures
- Cleansing, closure, and dressing
- Performance of other necessary interventions.
AIRWAY OBSTRUCTION
- Oropharyngeal/nasopharyngeal airway
insertion.
- Is a semicircular tube or tubelike plastic device
that is inserted over the back of the tongue into
the lower posterior pharynx in a patient who is
beathing spontaneously but who is
unconscious.
- This decides to help us provide same airway
access
- Inserting oropharyngeal airway
- (A) up
- (B) down
BAG MASK VENTILATION
- A handheld device commonly used to provide
positive pressure ventilation to patients who
are not breathing or not breathing adequately.
- Press = chest rise
- It is difficult if one person is performing because
there is a possibility that it cannot sealed the
mask
- It is advisable that 2 nurses must do the
procedure.
- A-C fill (thumb is pressing down on the patient’s
nasal bridge.
ENDOTRACHEAL INTUBATION
- It is an acute airway condition
- Medical emergency
- To establish and maintain the airway in patients
with respiratory insufficiency or hypoxia.
- Laryngoscope – to visualize
- Always remember this is to remove the objects
that are blocking the airway
- Before inserting, make sure that the head of the
patient is tilt
- In some cases, (restless) might have a tendency
that their tooth will be removed. Since gahi ang
laryngoscope
- Kung masayop ug insert, it may take time.
- Make sure to always have a suction machine
- Always check the respiration of the patient
CARDIAC ARREST
- An early response and the use of ACLS protocols
- Patient at risk for sudden cardiac death
(CPR QUALITY)
- Push hard (at least 2 inches and fast and slow
complete chest recoil.
- Minimize interruption in compressions
- Avoid excessive ventilation
- Rotate compressor every 2 minutes, or sooner if
fatigued.
- If no advanced airway, 30:2 compression-
ventilation ratio
- Quantitative waveforms capnography
Intra-arterial pressure
(SHOCK ENERGY FOR DEFIBRILLATION)
- Biphasic
- Monophasic
(DRUG THERAPY)
- Epinephrine IV/IO dose: 1 mg every 3-5 minutes
- Amiodarone IV/IO dose: first dose 300 mg
bolus, second dose 150 mg
(ADVANCED AIRWAY)
- Endotracheal intubation or supraglottis
advanced airway
- Waveform capnography or capnography to
confirm and monitor ET tube placement
- Once advanced airway in place, give 1 breath
every 6 seconds with continuous chest
compression.
(RETURN AND SPONTANEOUS CIRCULATION)
- Pulse and blood pressure
- Abrupt sustained increase in PETCO
- Spontaneous arterial pressure waves with intra-
arterial monitoring.
EMERGENCY NURSING DAY 2 TRAUMATIC BRAIN INJURIES

HEMORRHAGE Mechanism of injury

• Results in the reduction of circulating blood Deceleration injury- na hit

volume is a main cause of shock
• Internal hemorrhage can hide in any anatomic Acceleration injury- brain is forcefully hit
spaces and compartments, resulting in shock. - Primary injury
- Secondary injury
GOAL
- Tissue ischemia
To reduce the bleeding, maintain adequate circulating
- Hypotension (low blood pressure)
blood volume for tissue organization, and prevent
- Hypercapnia (Excessive carbon dioxide)
shock.
- Brain edema

External Hemorrhage Classifications of Brain Injury

• Rapid physical assessment - Skull fracture

• Direct, firm pressure/ torniquet - Concussion
- Contusion
Tourniquets—in the case of an arterial bleed, - Cerebral hematoma
tourniquets placed proximal to the bleeding area can be - Epidural hematoma
effective in stopping bleeding. They are used as a
Missile Injury - Depressing and Perforating
temporizing measure—definitive management should
be established. MANAGEMENTS

- Diagnostics
MANAGEMENT - Surgical managements
- Should be judged and reassessed frequently - Nonsurgical managements
- Urgent fluid resuscitation - Nursing managements
- Maintenance of fluid are rarely appropriate, SPINAL CORD INJURY
given the large volume of obligatory fluids
infused into most critically ill patients Functional injury of spinal cord
-
- Complete injury
URGENT FLUID RESUSCITATION in any kind of - Incomplete injury
hemorrhage - Spinal shock
- Neurogenic shook
- Autonomic dysreflexia
TRAUMA - Assessment- ABC and muscle

- mechanisms of injury CHEST TRAUMA

- blunt trauma (decelerate)
- penetrating trauma
PHASES OF TRAUMA CARE
- Prehospital resuscitation
- Emergency department resuscitation
- Primary survey
- Secondary survey- FGLMNOPH (full set V/S,
Labs, Monitor attachments, Oxygen monitor,
Pain/Pharmacologic interventions, History)
- Resuscitation phase
A CXR is a standard X-ray in a multiply injured patient
Most of these patients will have suffered from minor
chest wall trauma from contact sports, assaults, or falls.
However, a small number will have sustained significant
chest wall trauma, with underlying damage to the lungs,
heart, great vessels, and/or abdominal organs.
Etiology:
- MVA, gunshot wound, stab wound
- Assessment
 - Classifications- blunt, penetrating ANAPHYLAXIS

RIB FRACTURE Often rapidly developing, severe hypersensitivity

reaction to an antigen to which an individual was
- Common in athletes and elderly
previously sensitized.
- Assessment
- Diagnostics Characterized by severe respiratory tract mucosal
- Managements edema and cardiovascular collapse secondary to
extreme vasodilation
FLAIL CHEST

Two or more adjacent rib fractures or detached

sternum that floats freely in the thorax NURSING DIAGNOSIS

Inhalation Injuries - Ineffective breathing pattern

- Decrease cardiac output
Acute injuries to your respiratory system and lungs.
- Impaired gas exchange
They can happen if you breathe in toxic substances,
- Fear/ anxiety/ powerlessness
such as smoke (from fires), chemicals, particle pollution,
- Possible knowledge deficit: Anaphylaxis
and gases. Inhalation injuries can also be caused by
extreme heat; these are a type of thermal injuries. PLANNING AND IMPLEMENTATION

NURSING DIAGNOSIS - Initial treatment

- Medication
- Ineffective breathing pattern related to
Epinephrine – used to treat life-
neuromuscular impairment
threatening allergic reactions
- Risk for aspiration: impaired laryngeal sensation
Antihistamine –
or reflex: impaired pharyngeal peristalsis or
Hydroxyzine –
tongue function.
Corticosteroids –
- Impaired laryngeal closure or elevation;
Aminophylline IV drip –
increased gastric volume, decreased lower
- Assume respiratory position
esophageal sphincter pressure.
- Monitor vital signs
- Impaired gas exchange related to ventilation-
- Assist for rapid intubation
perfusion mismatching
- Start IV of normal saline solution / lactated
- Risk for ineffective cerebral tissue perfusion.
ringer
MANAGEMENTS - Assist for lavage
- Do not forcefully remove insect stings
Diagnostics: fiberoptic bronchoscopy - Observe other reactions: flushing, rashes, and
Plan and implementation: edema
- Decrease anxiety and fear
- Monitor hemodynamic status - Be aware of potential complications
- Provide supplemental humidified o2 and - Be sure someone can stay with the client.
bronchodilators
- Be aware that intubation and mech vent is most
effective
- Obtain cultures at regular intervals
- Monitor ABG and SPO2
- Maintain turning, positioning, and suctioning
PRN
- Monitor ECG and SaO2
- Obtain cray as ordered
- Use closed, in line suctioning systems
- Use specialty bed