1.

The following clients present to a walk-in clinic at the

same time. Which should the nurse schedule to be seen
first?
A. 25 year old with high fever, vomiting and diarrheab. 38 year old
with sore throat, fever, and swollen lymph glandsc. 40 year old
with severe headache, vomiting and stiff neckd. 44 year old
limping on a very swollen bruised ankle
2. The nurse just received report on the following clients.
Who should the nurse see first?
a. 35 year old with suspected acute tubular necrosis, urine output
totaled 25cc’s for the last two hours.b. 49 year old with cancer of the
breast, 2 days post mastectomy, reported to be having difficulty
coping with the diagnosis.c. 54 year old with TB in respiratory
isolation, requesting pain medicationd. 36 year old with chest tube
insertion after a spontaneous pneumothorax, respirations 16
3. As a nurse working the ER, which client needs the most
immediate attention?
a. a 3 yr old with a barking cough, oxygen sat of 93 in room air, and
occasional inspiratory stridorb. a 10 month old with a tympanic
temperature of 102, green nasal drainage, and pulling at the earsc. an
8 month old with a harsh paroxysmal cough, audible expiratory
wheeze and mild retractionsd. a 3 year old with complaints of a sore
throat, tongue slightly protruding out his mouth, and drooling.
4. The charge nurse is apporached by a new graduate nurse
who has been assigned four clients: a diabetic with a 4:00 pm
blood sugar of 99, a cardiac client with a potassium of 3.3,; a
client with pyelonephritis with a temperature of 100.8, and an
adult client with a 20% second degree burn of the legs. Which
client should the charge nurse suggest to assess first?
a. the diabeticb. the cardiac clientc. plelonephritis clientd. burn client
1. The emergency nurse has had specialized education, training,
and experience.

2. The emergency nurse establishes priorities, monitors and

continuously assesses acutely ill and injured patients,
supports and attends to families, supervises allied health
personnel, and teaches patients and families within a time-
limited, high-pressured care environment.
3. Nursing interventions are accomplished interdependently, in
consultation with or under the direction of a licensed
physician.

4. Appropriate nursing and medical interventions are anticipated

based on assessment data.

5. The emergency health care staff members work as a team in

performing the highly technical, hands-on skills required to
care for patients in an emergency situation.
6. Patients in the ED have a wide variety of actual or potential
problems, and their condition may change constantly.

7. Although a patient may have several diagnosis at a given

time, the focus is on the most life-threatening ones
1. A nurse on the cardiac unit is caring for four clients in the
emergency room. Which client should the nurse assess first?a) a
client scheduled for cardiac ultrasound this morningb) a client with
syncope being discharged todayc) a client with chronic bronchitis
on nasal oxygend) a client with a diabetic foot ulcer that needs a
dressing change
2. A nurse enters a room and finds lying face down on the floor,
bleeding from a gash in the head. Which action should the nurse
perform first?a) determine level of consciousnessb) push the call
button for helpc) turn the client face up to assessd) go out in the
hall to get the nursing assistant to stay with the client while the
nurse calls the physician
2. A nurse enters a room and finds lying face down on the floor,
bleeding from a gash in the head. Which action should the nurse
perform first?a) determine level of consciousnessb) push the call
button for helpc) turn the client face up to assessd) go out in the
hall to get the nursing assistant to stay with the client while the
nurse calls the physician
You are on duty in the ED when a code is called overhead.
As the code nurse, you grab the crash cart and run to the
code, which is in the employees lounge of the operating
room. On the couch you find a nurse unconscious, cyanotic
and barely breathing. His scrub shirt has been cut off, and
you attach ECG leads to his chest. His pulse is 45;
respirations are 8 and shallow.
You are on duty in the ED when a code is called overhead.
As the code nurse, you grab the crash cart and run to the code, which is in the employees
lounge of the operating room. On the couch you find a nurse unconscious, cyanotic and
barely breathing. Her scrub shirt has been cut off, and you attach ECG leads to her chest.
Her pulse is 45; respirations are 8 and shallow.

A. INTUBATION
B. IV LINE INSERTION
C. DEFIBRILLATION
D. CHEST TUBE INSERTION
E. SURGICAL PREPARATION
You are on duty in the ED when a code is called overhead.
As the code nurse, you grab the crash cart and run to the code, which is in the employees
lounge of the operating room. On the couch you find a nurse unconscious, cyanotic and
barely breathing. Her scrub shirt has been cut off, and you attach ECG leads to her chest.
Her pulse is 45; respirations are 8 and shallow.

A. MORPHINE
B. NALOXONE
C. ATROPINE
D. DEXAMETHASONE
E. D5 LR
F. 0.9% NaCl
G. D5W
H. LASIX
You are on duty in the ED when a code is called overhead.
As the code nurse, you grab the crash cart and run to the code, which is in the employees
lounge of the operating room. On the couch you find a nurse unconscious, cyanotic and
barely breathing. Her scrub shirt has been cut off, and you attach ECG leads to her chest.
Her pulse is 45; respirations are 8 and shallow.

A. MORPHINE
B. NALOXONE
C. ATROPINE
D. DEXAMETHASONE
E. D5 LR
F. 0.9% NaCl
G. D5W
H. LASIX
 Preserve or prolong life

 Alleviate suffering

 Do no further harm

 Restore to optimal function

A - ASK FOR HELP

I - INTERVENE

D - DO NO FURTHER HARM
 Assessment
 Priority setting/critical thinking skills
 Knowledge of Emergency Care
 Technical skills
 Communication skills
CHAIN OF SURVIVAL

• EARLY ACCESS – early recognition of

cardiac arrest, prompt activation of
emergency services

• EARLY BLS – prevent brain damage, buy

time for the arrival of defibrillator

19 DaRRaN
CHAIN OF SURVIVAL

• EARLY DEFIBRILLATION

• EARLY ACLS – technique that

attempts to stabilize patient

20 DaRRaN
I. Survey the Scene
A. Is the scene is safe?
B. What happened?
C. Are there any bystanders who can
help?
D. Identify as a trained first aiders.
II. Do a Primary Survey
A - Airway/Cervical Spine
 Establish Patent Airway
 Maintain alignment
B - Breathing
 Assess breath sounds
 Observe for chest wall trauma
 Prepare for chest decompression
C - Circulation
 Monitor VS
 Maintain vascular access
 Direct pressure
DaRRaN
24
D - Disability
 Evaluate LOC
 Re-evaluate clients LOC

E - Exposure
 Remove clothing
 Maintain privacy
 Prevent hypothermia
III. Activate Medical Assistance
A. Information to be relayed:
- What happened?
- Number of persons injured
- Extent of injury and first aid given
- Telephone number from where you
are calling
IV. Do Secondary Survey
A. Interview the Patient
S - Symptoms
A - Allergies
M - Medication
P - Previous/Present Illness
L - Last Meal Taken
E - Events Prior to Accident
B. Check the vital signs

V. Triage
- Comes from the French word “trier”,
meaning to sort
1. Emergent
-highest priority, conditions
are life threatening and need
immediate attention
2. Urgent
– have serious health
problems but not immediately
life threatening ones. Must be
seen within 1 hour

DaRRaN
29
3. Non-urgent
– patients have episodic
illness than can be addressed
within 24 hours without
increased morbidity

30
1. Immediate:
Injuries are life-threatening but
survivable with minimal
intervention. Individuals in this
group can progress rapidly to
expectant if treatment is delayed.
2. Delayed:
Injuries are significant and require
medical care, but can wait hours
without threat to life or limb..
3. Minimal:
Injuries are minor and treatment
can be delayed hours to days.
Individuals in this group should
be moved away from the main
triage area.
4. Expectant:
Injuries are extensive and chances
of survival are unlikely even with
definitive care.

5. Fast-Track:
Psychological support needed
Result of an external force
applied to the head and
brain causing disruption of
physiologic stability
locally, at the point of
injury

Trauma to the skull resulting

in mild to extensive
damage to the brain.
1. Open
- Scalp lacerations
- Fractures in the skull
- Interruption of the dura mater

2. Closed
Concussions
Contusions

3. Hemorrhage
causes hematoma or clot
formation
1. Epidural Hematoma

2. Subdural Hematoma

3. Intracerebral Hemorrhage
 Altered level of
consciousness
 Confusion

 Papillary abnormalities

 Altered or absent gag reflex

or vomiting
Absent corneal reflex

 Sudden onset of neurologic

deficits
 Vision and hearing
impairment
CSF drainage from ears or
nose
Sensory dysfunction

 Spasticity
Headache and vertigo
 Movement disorders or
reflex activity changes
Seizure activity
GOAL: Maintain oxygen and
nutrient rich cerebral blood
flow
1.Monitor respiratory status
and airway
2.Neurologic status and VS
3.Monitor inc. ICP
4.Head elevation 20-30
degrees
5.Restrict fluids and monitor I
and O
6.Immobilization of neck
7.Initiate normothermia
measures
GOAL: Maintain oxygen and
nutrient rich cerebral blood
flow
8. Assess cranial nerve fxn,
reflexes, and motor and
sensory fxns.
9. Initiate SZ precautions.
10. Monitor for pain and
restlessness
11. Avoid administration of
morphine sulfate
12. Monitor for drainage from
the nose or ears.
GOAL: Maintain oxygen and
nutrient rich cerebral blood
flow
13. If there are leaks, monitor
for nuchal rigidity.
14. Do not attempt to clean
the nose, suction or allow the
client to blow the nose if
drainage occurs
15. do not clean te ear of
drainage when noted but
apply a loose, dry sterile
dressing
1.Osmotic diuretics
2.Loop diuretics
3.Opioids
4.Sedatives
5.Antiepileptic drugs
 Approximately a quarter of deaths
due to trauma are attributed to
thoracic injury.
 Reasons of immediate deaths
 Reasons of early deaths
1. BLUNT TRAUMA
Example: Rib fractures

2. PENETRATING TRAUMA
Management:

1. Rest

2. Ice Compress then Local Heat

3. Analgesia

4. Splint the chest during

coughing or deep breathing
FLAIL CHEST

The unstable segment moves separately and in

an opposite direction from the rest of the
thoracic cage during the respiration cycle.

Assessment:
- Paradoxical respirations
- Severe chest pain
- Dyspnea/ Tachypnea
- Cyanosis
- Tachycardia
Management:

1. High Fowler’s position

2. Humidified O2
3. Analgesia
4. Coughing & deep breathing
5. Prepare for intubation with mechanical
ventilation
B. Penetrating Chest Trauma
- occurs when a foreign object penetrates the
chest wall
1.Pneumothorax
- Accumulation of atmospheric air in
the pleural space
may lead to lung collapse
Types:

1.Spontaneous Pneumothorax
2.Tension Pneumothorax
Assessment:
o Dyspnea
o Tachypnea
o Absent breathe sounds
o Sucking sound
o Cyanosis
o Sharp chest pain
o Tachycardia
Management:
1. Apply dressing over an open chest wound
2. O2 as Rx
3. High Fowler’s
4. Chest tube placement
- Monitor for chest tube system
- Monitor for subcutaneous emphysema
Chest Tube Drainage System
- returns (-) pressure to the intra-pleural
space
- remove abnormal accumulation of air &
fluids serves as lungs while healing is going
on
Pulmonary Embolism

- Dislodgement of thrombus to the

pulmonary artery

- Caused by thrombus & pulmonary

emboli

- Other risk factors: deep vein

thrombosis, immobilization,
surgery, obesity, pregnancy, CHF,
advanced age, prior History of
thromboembolism
Assessment
• Dyspnea
• Chest pain
• Tachypnea & tachycardia
• Hypotension
• Shallow respirations
• Rales on auscultation
• Cough
• Blood-tinged sputum
• Distended neck veins
• Cyanosis
Management
1. O2 as Rx
2. High Fowler’s
3. Maintain bed rest
4. Incentive spirometry as Rx
5. Pulse oximetry
6. Prepare for intubation & mechanical
ventilation
7. IV heparin (bolus)
8. Warfarin (Coumadin)
9. Monitor PT & PTT closely
10. Prepare the client for embolectomy, vein
ligation, or insertion of an umbrella filter as
Rx
ABDOMINAL TRAUMA
A. Penetrating Abdominal Trauma
Causes:
- Gunshot wound
- Stab wound
- Embedded object from explosion

Assessment:
- Absence of bowel sound - Hypovolemic
shock
- Orthostatic hypotension - Pain and
tenderness

Management:
1. Maintain hemodynamic status – IVF & blood transfusion
2. Surgery- EXLAP
3. Peritoneal Lavage
B. Blunt Abdominal Trauma
Assessment:

- Left upper quadrant pain (Spleen)

- Right upper quadrant pain (liver)
- Signs of hypovolemic shock
Management:

1. Maintain hemodynamic status

2. Monitor VS and oxygen supplements
3. Assess signs and symptoms of shock
FOREIGN BODY
AND
AIRWAY
OBSTRUCTION
CAUSES:

 improper chewing of large pieces of food

 aspiraton of vomitus, or a foreign body

 position of head, the tongue

 resulting to difficulty of breathing or

respiratory arrest

60 DaRRaN
 Types of Obstruction

I. Anatomical
» – tongue and epiglottis

I. Mechanical
» – coins, food, toy etc
Assessment and Clinical
Manifestations
• 1. Mild airway obstruction
– - can talk, breath and cough with
high pitch breath sound
– - cough mechanism not effective
to dislodge foreign body
• 2. Severe airway obstruction
– - can’t talk, breath or cough
• 3. Nasal flaring, cyanosis, excessive salivation

62 DaRRaN
Intervention:
CONCIOUS PATIENT:

• 1. Ask the victim, “are you choking?”

• 2. If the victim’s airway is obstructed partially, a crowing
sound is audible; encourage the victim to cough.
• 3. Relieve the obstruction by heimlick maneuver
• A. Heimlich maneuver:
- stand behind the victim
- place arms around the victim’s waist
- make a fist
- place the thumb side of the fist just above the umbilicus
and well below the xyphoid process.
- Perform 5 quick in and up thrusts.
- Continue abdominal thrusts until the object is
dislodged or the victim becomes unconscious.

63 DaRRaN
 • UNCONSCIOUS PATIENT

1. Assess LOC
2. Check for ABCs
3. Open airway using jaw thrust technique
4. Finger sweep to remove object
5. Attempt ventilation
6. Reposition the head if unsuccessful; reattempt ventilation
7. Relieve the obstruction by the Heimlich maneuver with five
thrust; then finger sweep the mouth
8. Reattempt ventilation
9. Repeat the sequence of jaw thrust, finger sweep, breaths
and Heimlich maneuver until successful
10. Be sure to assess the victim’s pulse and respirations
11. Perform CPR if required

64 DaRRaN
 Choking Child or Infant

 Choking is suspected in infants and children experiencing

acute respiratory distress associated with coughing,
gagging, or stridor.
 Allow the victim to continue to cough if the cough is
forceful
 If cough is ineffective or if increase respiratory difficulty is
still noted, perform CPR

65 DaRRaN
 Foreign Objects in the Ear
– Don’t probe the ear with a tool

– Remove the object if clearly visible

– Try using gravity and shake the head gently

– Try using oil for an insect

– Don’t use oil to remove any other object than an

insect
 Foreign Objects in
the Eye

• Flush eye clear with use of water

 Foreign Objects in the Nose

• Don’t probe at the object with cotton ball or other tool

• Breathe thru your mouth until the object is removed

• Blow your nose gently to try to free the object

POISONING

69 DaRRaN
• Poison

–Any substance that impairs

health or destroys life when
ingested, inhaled or
otherwise absorbed by the
body.

70 DaRRaN
Suspect poisoning if:

1. Someone suddenly becomes ill for no apparent

reason and begins to act unusually
2. Is depressed and suddenly becomes ill
3. Is found near a toxic substance and is breathing any
unusual fumes, or has stains, liquid or powder in his
or her clothing, skin or lips

1. 71 1. DaRRaN
 Ingestion Poisoning

• Botulism – Clostridium botulinum. From canned foods

• Staphylococcus Aureus – from unrefrigerated pack filled

foods, fish

• Petroleum Poisoning – includes poisoning with a substance

such as kerosene, fuel, insecticides and cleaning fluids
• Acetaminophen Poisoning – most common drug accidentally
ingested by children

• Corrosive Chemical Poisoning – strong detergents and dry

cleaners
• results in drooling of saliva, painful burning sensation and pain and
redness in the mouth
Diagnostics:
1. Baseline ABG should be obtained periodically
2. Baseline blood samples
3. ECG

Assessment:
– Headache
– 2. Double vision
– Difficulty in swallowing, talking and breathing
– Dry sore throat
– Muscle incoordination
– Nausea and vomiting

74 DaRRaN
 Management

1. Check victim’s ABCs.

2. If victim starts having seizures, protect him
from injury
3. If victim vomits, clear the airway
4. Calm and reassure the victim while calling
for medical help

75 DaRRaN
P – Prevention. Child Proofing
O – Oral fluids in large amount
I- Ipecac
S – Support respiration and
circulation
O - Oral Activated Charcoal
N - Never induce vomiting if
substance ingested is
corrosive

76 DaRRaN
 Inhalation
Poisoning
• Carbon Monoxide Poisoning
- Carbon monoxide is a colorless, odorless &
tasteless gas

Assessment:
- appears intoxicated
- Muscle weakness
- Headache & dizziness
 Management
1. Check ABCs

2. Remove victim from exposure

3. Loosen tight clothing

4. Administer O2 (100% delivery)

5. Initiate CPR if required

78 DaRRaN
BURN TRAUMA

Is the damage caused to skin and

deeper body structures by heat
(flames, scald, contact with heat),
electrical, chemical or radiation.
FACTORS DETERMINING
SEVERITY OF BURN

1. Age

2. Patient’s medical condition

3. Location

4. Depth
 4. Depth

Affected Part Description of Wound What to Expect

Classification

1st degree Epidermis Pin, painful “sunburn” Discomfort last after 48 hrs; heals in 3-7 days
superficial Blisters form after 24
hours

2nd degree Pediermis and part of Red, wet blisters, bullae Heals in 2-3 weeks, in no complication
partial thickness the dermis very painful

2nd degree Only the skin Waxy white, difficult to Slow to heal 94-8 weeks) surgical incision and grafting unless has
deep partial thickness appendages in the hair distinguish from 3rd complication
follicle remain degree except hair
growth becomes
apparent in 7-10 days,
little or no pain

3rd degree Epidermis, dermis and -Dry, leathery, Requires excision and grafting.
Full thickness subcutaneous tissue . no may be red or 10- 14 days for graft to revascularize
skin appendages black
-May have
thrombosed
veins
-Marked edema
-Distal
circulation may
be decreased
-Painless

4th degree Skin, muscle, tendon, Dry, charred, bone may Requires excision, grafting and sometimes amputation
deep full thickness bonde be visible 81 DaRRaN
5. Size: Rule of nine

Child < 3 years Adult

Assessment old

Head and neck 18% 9%

1 arm 9% 9%

Posterior trunk 18% 18%

Anterior trunk 18% 18%

1 leg 14% 18%

Perineum 1% 1%

82 DaRRaN
6. Temperature
• determines the extent of injury

7. Exposure to the Source

– A. Thermal Burns – caused by exposure to

flames, hot liquids, steam or hot objects
– B. Chemical Burns – caused by tissue contact
with strong acids, alkalis or organic compounds
– C. Electrical Burns – result in internal tissue
damaging, alternating current is more
dangerous than direct current for it is
associated with cardiopulmonary arrest,
ventricular fibrillation
– D. Radiation Burns – are caused by exposure to
ultraviolet light, x-rays or a radioactive source.
 Types of Burns and their
Treatment
• Scald
1. Burn caused by hot liquid
2. Immediately flush the burn area with water (under a tap or hose
for up to 20 min)
3. If no water is readily available, remove clothing immediately as
clothing soaked with hot liquid retains heat
• Flame
– Smother the flames with a coat or blanket, get the victim on the
floor or ground (stop, drop, and Roll)
– Prevent victim from running
– If water is available, immediately cool the burn area with water
– If water is not available, remove clothing; avoid pulling clothing
across the burnt face
1. Airway
1. If face or front of the trunk is burnt, there could be burns to the
airway
2. There is a risk of swelling or air passage, leading to difficulty in
breathing
• Smoke inhalation
1. Urgent treatment is required with care of the airway,
breathing and circulation
2. When 02 in the air is used up by fire, or replaced by
other gases, the oxygen level in the air will be
dangerously low
3. Spasm in the air passages as a result of irritation by
smoke or gases
4. Severe burns to the air passages causing swelling and
obstruction
5. Victim will show signs and symptoms of lack of O2. He
may also be confused or unconscious

• Electrical
1. Check for “Danger”
2. Turn of the electricity supply if possible
3. Avoid any direct contact with the skin of the victim or
any conducting material touching the victim until he is
disconnected
4. Once the area is safe, check the ABCs
5. If necessary, perform rescue breathing or CPR

85 DaRRaN
• Chemical
1. Flood affected area with water for 20-30
min
2. Remove contaminated clothing
3. If possible, identify the chemical for
possible subsequent neutralization
4. Avoid contact with the chemical
• Sunburn
1. Exposure to ultraviolet rays in natural
sunlight is the main cause of sunburn
2. General skin damage and eventually
skin cancer develops
3. The signs and symptoms of sunburn are
pain, redness and fever
86 DaRRaN
When we treat man as he
is, we make him worse
than he is; when we treat
him as if he already were
what he potentially could
be, we make him what he
should be