Emergency Nursing
Emergency Nursing
Emergency Nursing
Emergency Nursing
Objectives
At the end of this session the student
should be able to:
1.Define the terms: emergency nurse and
triage;
2.Explain the process of triaging;
3.Identify the priority disorders in triaging;
and
4.Discuss how patients are managed
presenting with emergency disorders.
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Triage
Triage
sorts patients
based on the severity of health problems
Takes in account the immediacy with which
these problems must be treated
Triage Categories
Three levels
Emergent
Highest priority
Life threatening conditions
Must be seen immediately
Urgent
Serious problems
Not immediately life threatening
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Triaging Contd.
Nonurgent
Episodic illnesses
Address within 24hrs,
fast track
Simple first aid/primary care
Can be referred
Triage
Five level system
Resuscitation
Emergent
Urgent
Nonurgent
Minor
Triaging Contd.
The obvious first-priority patients are those
with multiple trauma:
A, B, C
Neuro
Health history
Head-to-toe assessment
Airway Obstruction
Head-Tilt-Chin-Lift Maneuver
Jaw-Thrust Maneuver
Oropharyngeal Airway Insertion
Endotracheal Intubation
Alternative Intubation Method
Cricothyroidotomy
EFGHI =
E- Expose the patient
F- *Full set of vital signs, *five
interventions (cardiac monitor, pulse
oximetry, urinary catheter, NG if not
contraindicated, lab studies)
G- giving comfort measurespain control,
reassurance to patient and family
H- history/ head to toe assessment
I- inspect for hidden injuries-log roll patient
to inspect posterior aspect.
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Trauma
An unintentional or intentional wound or injury
inflicted on the body from a mechanism
against which the body cannot protect itself
Collection of forensic evidence
A critical role of the nurse!
Documentation may be used in legal proceedings
If criminal activity suspected, bag clothes and
belongings and give to law enforcement; document
the name of officer
If suicide or homicide, must notify medical
examiner
Multiple trauma
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Priority management
15
Wounds
Restore physical integrity and function of injured
tissue, with minimal scarring and without infection
Wound cleansing
Primary closure
Delayed primary closure
Hemorrhage
Fluid Replacement
Control of External Hemorrhage
Control of Internal Bleeding
Hemorrhage
Management
Fluid replacement
Blood, crystalloids, colloids
If large volume rapid infusion, need to warm fluids to
prevent hypothermia
Control of External
Hemorrhage
Direct Pressure
Elevation
Compression of pressure points
(arteries, veins)
AVOID tourniquetscan compromise
loss of circulation and loss of limb
Environmental Emergencies:
Hypothermia
ABCs
Monitor VS, LOC, ECG, UO
Laboratory specimens
Determine what, when, and how much
substance was ingested
Signs and symptoms of poisoning and
tissue damage
Health history
Age and weight
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Psychiatric Emergencies
Overactive patients, violent behavior,
underactive or depressed patients and suicidal
patients
Management
Maintain the safety all persons and gain control of
the situation
Determine if the patient is at risk for injuring
himself or herself or others.
Maintain the persons self-esteem while providing
care
Determine if the person has a psychiatric history or
is currently under care to contact that therapist
Crisis intervention
Interventions specific to each of the conditions
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Psychological manifestations
Anxiety, insomnia, vague GI complaints
36
Assessment
Management
If abuse or neglect is suspected, primary concern is
for the safety of patient
Multidisciplinary
MD, RN, social worker, authorities
37
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
38