Emergency nursing

At the end of this unit, the student is able to :

1.Explain triage nursing, it’s benefits and goals.

2.Discuss knowledge and skills required in Triage Nursing.

3.Describe the processes of Triage.

4.Discuss emergency nursing.

5.Describe priority emergency measures instituted for any patient with

an emergency condition.

6.Discuss types of Assessment carried out during an Emergency.

7. Explain emergency care as a collaborative, holistic approach that

includes the patient, family and significant other.

 Triage is the process of determining the priority of patient

treatments based on the severity of their condition.

 The term comes from the French verb ‘trier’, meaning to separate,
sort, shift or select.

 The reason for performing triage in the ED is to ensure that each

patient is treated in order of clinical urgency and that the
treatment is appropriate and timely.

 Triage aims at promoting the safety of patients by ensuring

that timing of care and resource allocation is vital to the
degree of illness or injury.

Triage is a complex process involving decision-making

under uncertainty in an environment laden with emotion,
driven by urgency and constrained by negotiation.
To be a triage nurse, one must have at least 5 years of experience and
be the jack of all trades. (so that the nurse is able to work
independently at triage. They also need to complete the necessary
courses and or training in order to gain the position.

Ability to demonstrate application of Knowledge-

Triage skills include more than just the selection of a triage level
number for the patient.

 Direct observations during actual triage process prove very

helpful in validating triage competencies.
Ability to apply positive customer service skills-

 The ability to calm and reassure those presenting to

triage(multiple patients and families) is as important as the
skill of determining a correct level.
Senesce service with a smile
Benefits of Triage
 To expedite the delivery of timely- critical treatment for
patients with life threatening conditions
 To ensure that all patients requiring emergency care are
categorized according to their clinical condition
 The rationale is that patient treatment is carried out
efficiently when resources are insufficient and for all to be
treated immediately
 To improve patient flow and client satisfaction
 To decrease patients overall length of stay
 To ensure prompt response with emergencies to avoid death and
disability
 To streamline less urgent cases
 To be customer focused for all levels of health care
Goal – To get the right patient to the right place at the right time
for the right reason to receive the right treatment.
Aim – To minimize morbidity and mortality.
Purpose – To sort or classify all incoming ED patients and to set
priorities for care depending on the severity of the condition.
Length of time – commonly cited 2 –5 minutes
 To rapidly identify patients with urgent, life threatening
conditions
  To determine the most appropriate treatment area for clients
presenting to ED
 To decrease congestion in ED treatment areas
 To provide ongoing assessments of patients
 To provide information to clients and families regarding
services, expected plan of care and waiting times
Triage nursing and it’s different roles
 The triage nurse in the ED is the first medical responder that a
patient encounters and the nurse’s knowledge and skills has been
cited as an influential factor in triage decision making.
 Refers to the rapid, focused assessment of patients seeking
ED care in a way that allows for the most efficient use of
manpower, equipment and facilities.
 The role of the triage nurse is to make a first quick assessment
on any incoming patient to the emergency room.
 To do a brief evaluation of the patient to determine a level of
acuity or priority of care.
 The triage nurse act as a gate keeper, sorting patients into
categories, ensuring that the most seriously ill are treated
first.
 He/She will be in the process of collecting relevant information
about patients who are seeking emergency care and initiating a
decision-making procedure that uses a valid and reliable triage
acuity system.
 Rapid and accurate triage decisions are important for successful
ED operations and optimal patient outcomes.
Who should perform the role of Triaging?
-Safe, effective and efficient triage can be performed only by a
registered professional nurse.

 Presentations to ED range across a wide spectrum of cases of all

ages, encompassing medical, surgical, obstetric, pediatric and
psychosocial emergencies.

 These cases may present as immediate or potentially life-

threatening cases such as major trauma, acute cardiac/
respiratory diseases or acute psychological distress or less
urgent cases such as minor wounds or localized infections.

 Many ED nurses assume advanced practice roles where they are

responsible for advanced assessment and patient management
 strategies, undertaking activities which were considered solely
the domain of medical officers.
Triage Process
 Assessment should be timely and brief-gather sufficient
information about the patient to make a triage severity rating
decision.
 All patients to receive an initial triage assessment within 5
minutes of arrival in ED.
 Triage begins with an across the room assessment and then
continues in the privacy of the triage booth or room.
 The triage nurse must be able to identify life- threatening
airway, breathing or circulatory problem and initiate appropriate
intervention immediately.

Across-the room Assessment

 Begins when the triage nurse first sees the patient
- Should observe closely, listen for abnormal sounds and be aware of
odors.
An experienced triage nurse should take one look at the patient and
based on general appearance, decides whether immediate care is
required.

• The initial greeting by the triage nurse can set the tone for the
whole ED visit.

Interview

• The objective of the triage interview is to establish the chief

complaint, obtain a description of relevant signs and symptoms,
perform a targeted history and examination and assign a patient
severity rating.

• The nurse determines the chief complaint and the history of the
present injury /illness.

• Nurse need to be nonjudgmental and empathetic

• Elicit chief complaint: The first question to ask is:

“What brought you in to see us today?
Some chief complaints can carry higher risks than others, eg., chest
pain would be a higher- risk chief complaint than toe injury.
Triage is not the time to conduct an entire head to toe assessment.
Ask questions only that relate to the chief complaint
 Most ER triage screening tools include the following:
a)Duration of the chief complaint
b)Related symptoms
c)Mechanism of injury 
This determines the urgency plus order in
which the patient will receive a medical
d)Medical history
examination & additional assessment and
e)Current medications(prescription/non-prescription)
treatment will be based on the triage
decision, in which the patient’s acuity or
f)Immunizations
level is assigned. Always accurately weigh
g)Last menstrual period pediatric patients, their medications are
based on their current weight.
h)Allergies
i)Height and weight
- Triage process should only take about 2-5 minutes.

Emergency Nursing
is a specialty within the field of professional nursing focusing on
the care of patients with medical emergencies,ie,those who require
prompt medical attention to avoid long-term disability or death.
-emergency care can be defined as the episodic and crisis oriented
care provided to patients with serious or potentially life threatening
injuries or illnesses.
Emergency room (ER) nurses need to be able to handle a broad spectrum
of patients spanning all ages from newborn to centenarians.

 A competent ER nurse must be a ‘jack-of-all trades', 'master of

most’ and constantly prepared for EVERY conceivable scenario., as
they can combat any type of situation.

 Must also have a good working knowledge of the many legal issues
impacting health care such as consent, handling of evidence,
child welfare decree, reporting of child and elderly abuse and
involuntary holds.
A emergency nurse is typically assigned to triage patients as they
arrive in ED. The nurse must be skilled at rapid, accurate physical
examination and early recognition of life threatening conditions.
In some situations, the emergency nurse may order certain tests, and
medication following ‘collaborative practice guidelines’ set out.
Challenges of Emergency Nursing.
  Is a demanding job and is unpredictable.
 Need to have basic knowledge of most specialty areas, is able to
work under pressure, communicate effectively with many types of
patients

 Must collaborate with a variety of health care providers and

prioritize tasks that must be performed.

 It is quite draining both physically and mentally as they spend

most of their time on their feet and are always ready for
unexpected changes in patient’s conditions as well as sudden
influxes of patients.

 Violence is a concern for many emergency nurses in ED as they

often receive both physical and verbal abuse from patients and
visitors.

Essential Assessment tools for the ER nurse:

 Interpersonal skills
 Physical assessment skills
 Ability to apply critical thinking to each patients’ unique
situation

LO:5-Prioritizing emergency conditions
Choosing an Acuity Level:
-There is a variety of triage acuity(acuteness) systems used by
various hospitals.
-You must identify the triage acuity system that your facility is
using in the emergency department
While a facility maybe using a 5-level triage system another facility
could be using a 3-level triage acuity system.
- Based on the chief complaint and on subjective and objective data,
triage nurse use their knowledge, experience and triage guidelines to
assign a severity rating

Level 5-level 4-level 3-level 2-level

1 Resuscitation Life
threatening
requires
immediate life
 saving
interventions.

2 Emergent Emergent Emergent Emergent

3 Urgent Urgent Urgent

4 Less urgent Less-urgent Less- Non-emergent

urgent

5 Non-urgent

 Level 2 EMERGENT-a high risk situation, confused/ lethargic,

disoriented patient, in severe pain or distress or has
dangerously abnormal vital signs.
 Level 3 URGENT-requires many resources.
 Level 4 LESS-URGENT-requires just one resource.
 Level 5 NON- URGENT-requires no resources.

Resources:
Resources consists of labs, CT, X-ray, MRI, specialty consults,
simple procedures fluids or medications, imi medications, and inhaled
meds. There are some interventions that do not count as resources,
these include intravenous access, point of care testing, simple
dressings, slings, crutches and splints
Emergency Severity Index:
is determined by answering 4 simple questions:

 Is the patient dying right now?

 Is this a patient that can/cannot wait?

 How many resources are needed?

Level Level Level 3- Level 4 : Less
1:Resuscitative  What are the vital signs?
2:Emergent Urgent: Urgent

 Conditions that  Conditions  Condition  Condition

 are threats to that are s that s that
LIFE or LIMB(or potential could are
imminent risk threat to potential related
of life, limb ly to
deterioration)r or progress patient
equiring function, to a age,
aggressive requiring serious distress
interventions. rapid problem or
 Time to MO- medical requiring potential
immediately interventi emergency for
Assessment- on or intervention. deteriora
continuous delegated -maybe tion or
Code/arrest, major acts. associated complicat
trauma, severe  Time to with ions and
burns-airway MO-15 significant would
compromise. minutes. discomfort or benefit
-Shock states, Reassessment affecting from
severe respiratory time-15 minutes ability to intervent
distress, near death Chest pain function at ion or
asthma(status ?MI,trauma,chem work or reassuran
asthmaticus),altered ical exposure, activities of ce within
mental state stroke, altered daily living. 1-2
Tension consciousness, Time to MO- hours.
pneumothorax, Acute MI. <30minutes Time to MO-<
seizures(status -Severe asthma- Reassessment 60minutes
epilepticus), stridor, acute time- Reassessment
traumatic shock, psychotic 30minutes. time-
overdose, episode with Renal colic, 60minutes.
AAA(Abdominal Aortic agitation, biliary colic, Usual
Aneurysm, AMI(with severe pain(8- GI bleed, presentation-
complications),CHF 10). previous Head injury
with low B/P and seizures- but alert,
major head injury- alert, earache,
unconscious dehydration, abdominal
shunt pain, UTI
dysfunction, signs and
vital signs symptoms,
outside of simple
normal lacerations
range,pain requiring
scale(4- sutures.
7/10),moderate
risk of self
harm and to
others. -
Inconsolable
infant, baby
not feeding

Level 5: Non Urgent

 Conditions that maybe acute but non-urgent as well as conditions
 which maybe part of a chronic problem with/without evidence of
deterioration.
• The investigations or intervention could be delayed or even
referred to other area of the hospital.
Time to MO-120minutes.
Reassessment time-120minutes
Usual Presentation
Strains, sprains, single episode of vomiting, sore throat, script
refills, chronic problems with no change.

3 Levels of Acuity
EMERGENT 1  URGENT 2  NON EMERGENT 3

Conditions requiring Patients who present Patients who present

immediate as stable but whose with chronic or minor
interventions. Any condition requires injuries.
delay in treatment is medical intervention -There is no danger to
potentially life within a few hours. life by having these
threatening. -There is no immediate patients wait to be
Usual Presentation – threat to life for seen.
airway compromise, these patients. - These patients are
cardiac arrest, severe Usual Presentation – in no obvious
shock, cervical spine Fever, minor burns, distress.
injury, multisystem minor MSK injuries, Usual Presentation –
trauma, altered level dizziness, lacerations chronic low back pain,
of consciousness, routine medical
eclampsia. refills, dental
problems, missed
menses.

Prioritizing Acuity Levels> Color tags:

 RED –Need immediate attention
 YELLOW – Patients kept under observations need to be reviewed
 GREEN –Patients can wait , will require care in some hours
 WHITE – Walking around, having minor injuries only, can wait to
be seen
 BLACK – Clients who are unlikely to survive, prognosis is very
poor.
 Assessment-initial.

1st step-is the patient conscious? Primary assessment can be

performed at a glance. Patient alert and talking-there is
breathing and circulation. Conscious patient-shows that
ASSESSMENT TYPES circulation is adequate, enough blood is circulated to the
brain.
 Emergency Assessment
 Systemic Approach- neurological, respiratory, cardiovascular,
gastrointestinal, genitourinary, musculoskeletal, skin
PRIMARY ASSESSMENT
 Primary Assessment
 Initial rapid assessment of the patient is
 Secondary Assessment meant to identify life threatening
problems:

 Airway

 Breathing

 Circulation

AIRWAY BREATHING CIRCULATION:

 client  Assess for the Assess skin for:

vocalizing following- -Color,
sounds -spontaneous breathing, temperature,moisture,capillary
appropriate rate and pattern, refill, uncontrolled bleeding
for age? symmetrical rise and or trauma.
-check for fall, increased work of
obstruction or breathing(nasal
foreign material flarings,retractions),use
visible in the of accessory muscles,
oropharynx blood, chest wall
emesis, teeth, stability/integrity, skin
debris) color
-look for • If breathing is
swelling/edema to compromised
lips, mouth, tongue -assess lung sounds
or neck -bag-mask device
-is the patient assistance
drooling/dysphasic? -oxygen
Airway obstructed? -position-airway open
-head tilt(if no -assess lung sounds.
trauma)
-jaw thrust
suction
-airway adjunct(OPA-
oro-pharyngeal
airway, NPA-naso-
pharyngeal airway)
-prepare for
intubation
  DISABILITY:
A helpful mnemonic exists to assist in a brief neurologic assessment:
AVPU
Alert: Patient is alert, responsive to voice and is oriented to
person, time and place.
Verbal: Patient responds to voice but is not fully oriented to person,
time or place.
PAIN: Patient does not respond to voice but does respond to painful
stimulus.
UNRESPONSIVE: Patient does not respond to voice or painful AMPLE
stimulus.
mnemonic-

-Allergies-record severity and type of

reaction
EXPOSURE:
-Medications- Rx, OTC, Herbal,
 Remove the patient’s clothing to
Recreational, unprescribed
thoroughly examine and identify any underlying cause of injury or
illness. -Past Health History

 Cover the patient to maintain privacy -Last Meal Eaten

Ask yourself-Is he/she unconscious?

and heat loss -Events leading to injury/illness

 Check pupils- size, equality and
reaction to light.

 Further investigate during

Responsibilities of the Emergency room nurse-secondary assessment-secondary assessment.
once prescribed by MO, the ER nurse will be legally responsible to
administer medications.
 The history is the main presenting complaint.
-setting up and priming an
 This information can be obtained by questioning the patient, the
intravenous(IV) infusion. relative or by reading the referral letter.
 Always ask the question: What is their emergency or what brings
History
them to the hospital.
 Vital signs
 Head to toe assessment –
General appearance, head, scalp, ears, eyes, nose , mouth, neck, chest
,abdomen ,pelvis, genitalia, extremities, posterior- observe cervical
spine, precautions in trauma patients
Pain’ the 5th vital sign
-PQRST- Provoked, Quality, Radiation, Severity, Time.
Causes of ALOC

 AEIOUTIPPS
 A-Airway

 B-Breathing

 C-Circulation

 D-Disability
-Alcohol
-Epilepsy/Electrolyte
-Insulin (hypo/hyperglycemia)
-Opiates
-Uremia
-Trauma
-Infection
-Poison
-Psychosis
-Syncope
Nursing Intervention and Evaluation
 Once the secondary survey is complete, it is important to
document all assessment findings and a subsequent clear plan of
care.
 Accurate and clear documentation provides an on-going record of
the patient’s health status and the health care team responses.
 The nurse is responsible for providing appropriate nursing
interventions and assessing the patient’s response.
 The evaluation of airway patency and the effectiveness of
breathing and circulation will always be the priority.

 Monitoring respiratory rate and rhythm, SaO2 and ABGs(if ordered)

will assist in evaluating the patient’s respiratory status.
 Assessing the level of consciousness, vital signs, quality of
peripheral pulses, urine output, skin temperature, color and
moisture should be closely monitored.

 Depending on the injuries or illness the patient maybe –

 (1)transported for diagnostic tests(x-ray, CT-scan) or to the

Operating room for immediate surgery or (2) admitted to the ICU
or to a ward or (3) transferred to another facility.

 Critically ill patients requiring intra- hospital transfer

should be accompanied by experienced nursing and medical staff.

Special Population-
Pediatric vital signs, must include-
 -Heart rate (H/R),respiration rate(R/R),B/P,
SaO2,Temperature,capillary refill and accurate weight.
 Obtain temperature via an appropriate route considering the
pediatric patient’s age and condition.
 Avoid rectal temperatures in immunocompromised patients.
 Any fever can be associated with abnormal activity, respiratory
patterns or dermal warning signs such as rashes, cyanosis or
mottling.
 The determination of the acuity rating decision provides
conclusion for the urgency and order for care.

The Older Adult-

 Older adults , use the ED services more than any other group.
Knowledge of these physiologic changes is important in caring for
this vulnerable population in the ED.
Older adults seek emergency care for a variety of complaints which
ranges from acute pain, psychiatric disorders, urosepsis and
dehydration

LO:7-Collaborative & Holistic approach that includes the patient,

family and significant other
 The presence of family establishes an important source of
psychological stability for the patient (source of support).
 Nurses play an important role in the care of the patient and the
family
 collaborate with them by looking for opportunities to improve the
delivery of care.
 -empowering the patient and the family to be active participants
in care plans.
 For a pediatric patient, the nurse’s role is to support parents
coping with a child’s illness to allow them to provide better
care for child and enhances the stability and bond.
Important points-
  GOOD COMMUNICATION is important in collaboration, coordination,
empathy, rapport, respect and calming the environment.
 The ER nurse must always inform the patient(if
possible),relatives and significant others on the necessary
information to alleviate and promote good customer services in
dire( grim, disastrous) situations.
 INFECTION CONTROL-the ED is mostly the portal of entry for
patients with unknown status of immuno-compromised and other
contagious diseases, use UNIVERSAL PRECAUTIONS and ensure
HANDWASHING between patients.
 If a patient shows signs of a potential contagion, it is
important to inquire about recent foreign travel and trace
household contacts.
 As soon as the patient with the suspected communicable disease is
triaged, the triaged area needs to be cleaned before the next
patient enters..
 SAFETY and SECURITY-incidence of physical assault is increasing
in ED,maybe due to the fast paced, stressful
environment,overcrowding,long waiting time, influence of drugs
and mental health issues.
 person challenges the nurse’s authority or competence. ‘We’ve
been waiting for more than an hour. You people are all in
competent”
 Ignore the question but not the person. Redirect to the issue at
hand. Responding directly to the challenge
Eg., “Sir, we are all highly trained professionals here,” creates an
unproductive power struggle.

• Let the person vent. Do not interrupt. Do not deny the complaint.
Let the person verbalize ‘deflates’ his or her pent –up emotions.

• Respond with empathy, acknowledging the person’s emotions.

 “I can see you’re angry/I know you’re upset.”
 Keep body language non- threatening,
Use the person’s name often.
 The triage/ER nurse should not place themselves or others at risk
or to become the target of aggressive verbal or physical
behavior.
 Triage/ER nurse should be able to identify psychiatric patients
who cannot remain safely in the waiting room.
 The presence of one or more security guards will calm the
situation.