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Emergency Nursing
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Copyright © 2008 Lippincott Williams & Wilkins.
Scope and Practice of
Emergency Nursing
• Emergency management traditionally refers to
urgent and critical care needs; however, the ED
has increasingly been used for non-urgent
problems, and emergency management has
broadened to include the concept that an
emergency is whatever the patient or family
considers it to be
• The emergency nurse has special training,
education, experience, and expertise in
assessing and identifying health care problems
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in crisis situations
Copyright © 2008 Lippincott Williams & Wilkins.
Scope and Practice of
Emergency Nursing
• Nursing interventions are accomplished
interdependently in consultation with or
under the direction of a physician,
physician’s assistant, or nurse practitioner
• The emergency room staff works as a
team
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Priority Emergency Measures for
All Patients
• Make safety the first priority
– For patients, family and staff
• Preplan to ensure security and a safe environment
– Potential for violence in the ER
– May be related to emotional stress, substance
abuse, violent injuries
• Closely observe patient and family members in the
event that they respond to stress with physical violence
• Assess the patient and family for psychological function
• Documentation of consent
– If patient or next of kin unable to consent, nurse must
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carefully document circumstances
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Priority Emergency Measures for
All Patients (cont.)
• Patient and family-focused interventions
– Relieve anxiety and provide a sense of
security
– Allow family to stay with patient, if possible, to
alleviate anxiety
– Provide explanations and information
– Provide additional interventions depending
upon the stage of crisis
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Triage
• Triage (“to sort”) sorts patients by hierarchy based on
the severity of health problems and the immediacy with
which these problems must be treated
– Emergent, urgent, non life-threatening, fast track
– Emergency Severity Index (see table 69-2)
• The triage nurse collects data and classifies the
illnesses and injuries to ensure that the patients most in
need of care do not needlessly wait
• Protocols may be initiated in the triage area
• ED triage differs from disaster triage in that patients who
are the most critically ill receive the most resources,
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regardless of potential outcome
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Triage
• Systematic approach to manage
emergent or urgent situations. Primary
survey includes:
– Airway with cervical spine stabilization
– Breathing
– Circulation
– Disability (neurological)
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Triage
• Secondary Survey
– Exposure/environmental control
– Full set of vital signs
– Five interventions
• EKG, pulse ox, indwelling catheter, NG tube, labs
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–
–
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Family presence
Give comfort measures
History and head-to-toe assessment
Inspect posterior surfaces
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Common Emergencies
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Airway Obstruction
• Partial airway obstruction
• Complete airway obstruction
• Causes may include aspiration of foreign bodies or
food, anaphylaxis, infection, trauma, sedative
meds, neurologic dysfunction
• Management
– Establish an airway!
• Abdominal thrusts
• Head tilt, chin lift maneuver/jaw thrust maneuver (if cervical
spin injury suspected)
• Oropharyngeal airway
• Endotracheal intubation
• Cricothyroidectomy
– Maintain ventilation
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Hemorrhage
• Management
– Fluid replacement
• Blood, crystalloids, colloids
• If large volume rapid infusion, need to warm fluids to
prevent hypothermia
– Control of external hemorrhage, via direct
pressure; tourniquet used as a last resort
– Control of internal hemorrhage, usually via
emergent surgery; administer PRBCs while
awaiting surgery
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• Level 1
Rapid
Infuser
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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
– Priority managements
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Management of Patients With
Intra-Abdominal Injuries
• Blunt trauma (eg, fall) or penetrating injuries
(eg, gunshot wound)
• Abdominal trauma can cause massive lifethreatening blood loss into abdominal cavity
• Assessment
– Obtain history of injury
– Perform abdominal assessment and assess other
body systems for injuries that frequently
accompany abdominal injuries
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Management of Patients With
Intra-Abdominal Injuries (cont.)
• Assessment (cont.)
– Assess for referred pain that may indicate
spleen, liver, or intraperitoneal injury
– Perform laboratory studies, CT scan,
abdominal ultrasound and diagnostic
peritoneal lavage
– Assess stab wound via sonography
– Assess for hematuria (possible GU injury)
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Management of Patients With
Intra-Abdominal Injuries (cont.)
• Ensure airway, breathing, and circulation
• Immobilize cervical spine
• Continually monitor the patient
• Document all wounds
• If viscera are protruding, cover with a sterile, moist
saline dressing
• Hold oral fluids
• NG to aspirate stomach contents
• Provide tetanus and antibiotic prophylaxis
• Provide rapid transport to surgery if indicated
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Priorities of Care for the Patient
With Multiple Trauma
• Use a team approach
• Determine the extent of injuries and
establish priorities of treatment
• Assume cervical spine injury
• Assign highest priority to injuries
interfering with vital physiologic function
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Priorities in the Management of
the Patient With Multiple Injuries
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Priorities in the Management of
the Patient with Multiple Injuries
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Trauma
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Environmental Emergencies—
Heat Stroke
• A failure of heat regulating mechanisms of the body
• Elderly, very young, ill, or debilitated—and persons on
some medications—are at high risk (see table 39-7)
• Leads to thermal injury at the cellular level
• Manifestations:
– Initially, the body attempts to compensate with increased
sweating, vasodilation, and increased respiratory rate;
mechanisms become DEPLETED
– HEATSTROKE manifests as neurological dysfunction,
elevated temperature (may be > 104), hot dry skin,
anhydrosis (no sweating) , tachypnea, hypotension, and
tachycardia
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Management of Patients With
Heat Stroke
• Use ABCs and reduce temperature to <102 as quickly as
possible
• Cooling methods
– Cool sheets, towels, or sponging with cool water
– Apply ice to neck, groin, chest, and axillae
– Cooling blankets
– Iced lavage of the stomach or colon
– Immersion in cold water bath
• Monitor temperature, VS, ECG, CVP, LOC, urine output
• Use IVs to replace fluid losses
– Hyperthermia may recur in 3 to 4 hours; avoid
hypothermia
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Environmental Emergencies—
Frostbite
• Trauma from freezing temperature and actual freezing of
fluid in the intracellular and intercellular spaces; leads to
cellular and vascular damage
• Manifestations: hard, cold, and insensitive to touch; may
appear white or mottled; and may turn red and painful as
rewarmed
• The extent of injury is not always initially known
– 1st to 4th degree
• Controlled but rapid rewarming; 37° to 40° C circulating
bath for 30- to 40-minute intervals
• Administer analgesics for pain
• Do not massage or handle; if feet are involved, do not
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allow patient to walk for 24-48 hours
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Frostbite
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Environmental Emergencies—
Frostbite
• After rewarming:
– Observe for development of infection (high
risk)
• May require amputation
– Active ROM to restore function and prevent
contractures
– Avoid tobacco, ETOH, caffeine
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Environmental Emergencies—
Hypothermia
• Internal core temperate is 95 degrees F or less
– Severe if less than 86 degrees F
• Elderly, infants, persons with concurrent illness, the
homeless, and trauma victims are at risk
• Alcohol ingestion increases susceptibility
• Hypothermia may be seen with frostbite; treatment of
hypothermia takes precedence
• Physiologic changes in all organ systems;
manifestations correlate with degree of severity
– Shivering, lethargy, confusion; rigidity, bradycardia,
metabolic and respiratory acidosis, hypovolemia;
may progress to dysrhythmia, renal failure, thrombi
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Copyright © 2008 Lippincott Williams & Wilkins.
Management of Patients With
Hypothermia
• Use ABCs, remove wet clothing, and rewarm
• Rewarming
– Active core rewarming
 Cardiopulmonary bypass, warm fluid administration,
warm humidified oxygen, and warm peritoneal lavage
– Passive external rewarming
 Warm blankets and warm place
 Active external rewarming
 Warming blankets, radiant heat lamps
• Cold blood returning from the extremities has high levels of
lactic acid and can cause potential cardiac dysrhythmias and
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electrolyte disturbances
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Management of Patients With
Hypothermia
• Supportive care during rewarming:
– Cardiac compression
– Defibrillation for V fib - ineffective in patients with a
core temperature < 31 degrees (88)
• The patient is not dead until he is warm and dead!
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Airway support
Warm IV fluids
Sodium bicarbonate to correct acidosis
Foley insertion to monitor UOP
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Management of Patients With
Poisoning
See table 69-12
• Poison is any substance that when ingested,
inhaled, absorbed, applied to the skin, or produced
within the body in relativity small amounts injures
the body by its chemical action
• Treatment goals:
– Remove or inactivate the poison before it is absorbed
– Provide supportive care in maintaining vital organ systems
– Administer specific antidotes
– Implement treatment to hasten the elimination of the poison
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Management of Patients With
Poisoning
• Options for decreasing absorption
– Gastric lavage via NGT with saline
• Contraindicated in ingestion of caustic agents, coingested sharp
objects, ingested nontoxic substances
• Must be done within 2 hours of ingestion
– Activated charcoal
• Some toxins will adhere to charcoal and are excreted via the GI
tract
• Does NOT absorb ethanol, alkali, iron, lithium, methanol or
cyanide
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Management of Patients With
Poisoning
• Skin and ocular decontamination
– Removal of toxins from eyes and skin with water and
saline
– Do not use for mustard gas
• Cathartics
– Stimulate intestinal motility and increase elimination
• Dilution (with water or milk)
• Hemodialysis
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Assessment of Patients With
Ingested Poisons
• Use ABCs
• Monitor VS, LOC, ECG, and UO
• Assess laboratory specimens
• Determine what, when, and how much substance was
ingested
• Assess signs and symptoms of poisoning and tissue
damage
• Assess health history
• Determine age and weight
• *If details about specific poison are unknown, call the 32
local poison control center*
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Management of Patients With
Ingested Poisons (cont.)
• Corrosive agents such as acids and
alkalis cause destruction of tissues by
contact; DO NOT induce vomiting with
corrosive agents!
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Management of Patients With
Ingested Poisons (cont.)
• Specific poison management in Table
69-12
– Acetaminophen
– Acids and alkali
– Carbon monoxide
– Tricyclic antidepressants
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Management Patients With
Carbon Monoxide Poisoning
• Inhaled carbon monoxide binds to hemoglobin as
carboxyhemoglobin, which does not transport oxygen
• Manifestations: CNS symptoms predominate due to
hypoxia
– Other - headache, muscle weakness, dizziness, palpitations
– Skin color is not a reliable sign and pulse oximetry is not
valid - need ABG and carboxyhemoglobin level
• Treatment
– Get to fresh air immediately
– Perform CPR as necessary
– Administer oxygen: 100% or oxygen under hyperbaric pressure
• Monitor patient continuously
• May cause permanent brain damage
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Management of Patients With
Food Poisoning
• A sudden illness due to the ingestion of
contaminated food or drink
• Food poisoning, such as botulism or fish
poisoning, may result in respiratory paralysis and
death; most of the time it involves the GI tract,
such as N/V, diarrhea
• ABCs and supportive measures
• Determination of food poisoning source
• Treat fluid and electrolyte imbalances
• Control nausea and vomiting
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Management of Patients With
Substance Abuse
• Acute alcohol intoxication:a multisystem toxin (See table
12-11)
– Alcohol poisoning may result in death
– Maintain airway and observe for CNS depression and
hypotension
– Rule out other potential causes of the behaviors before it is
assumed the patient is intoxicated (eg, hypoglycemia)
– Use a nonjudgmental, calm manner
– Patient may need sedation if noisy or belligerent - careful use
– Examine for withdrawal delirium, injuries, and evidence of
other disorders
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Management of Patients With
Substance Abuse
• OVERVIEW OF SUBSTANCE MANAGEMENT
• Cocaine and Amphetamines(see table 12-7)
– Airway
– Seizure control
– Cardiac effect management; defib, antiarrhythmics
– Benzodiazepines or haloperidol for psychosis
– Treatment of hypertension
• Opiates (see table 12-11)
– Support respiratory and cardiovascular function
– Antagonist - Narcan (naloxone)
• Administer slowly; watch for rebound depression
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Alcohol Withdrawal - Delirium
Tremens
• Acute toxic state that occurs as a result of sudden
cessation of ETOH intake after a heavy bout or
prolonged intake of ETOH
• Manifestations
– Anxiety, irritability, agitation, hallucinations, signs of
autonomic overactivity; VS are elevated
– High mortality rate
• Give adequate sedation and support to allow the
patient to recover without danger of injury
• Sedation with benzodiazepine and others
– Lorazepam, chlordazepoxide, clonidine, haloperidol
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Alcohol Withdrawal - Delirium
Tremens
Calm, quiet environment
•
• Close observation
• Restraints if necessary, but only if no other
alternative
• Physiologic
– Monitor for fluid loss and lyte imbalance, monitor
for seizures, treat hypertension, hypoglycemia
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Sexual Abuse
• Rape is defined as forcible penetration act on
a person without his or her consent
• Patients reaction to rape - rape trauma
syndrome (Post traumatic stress disorder)
– Disorganization phase
– Denial and unwillingness to talk
– Reorganization phase
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Crisis Intervention—Rape Victims
• How the patient is received and treated in the ED is
important to his or her psychological well-being
• Crisis intervention begins as soon as the patient enters
the facility; the patient should be seen immediately
• Goals are to provide support, reduce emotional
trauma, and gather evidence for possible legal
proceedings
• Patient reaction; rape trauma syndrome
• History taking and documentation
• Physical examination and collection of forensic
evidence
• Role of the sexual assault nurse examiner (SANE)
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Family Violence, Abuse and
Neglect
• 5.3 million domestic violence cases in US
every year
• PREGNANCY is a major risk factor for
domestic violence
– 4-14% suffer violence from intimate partner
– Severity and frequency of abuse increases
during pregnancy
• 1-2 million cases of elder abuse each year
– May include physiologic and pychological abuse,
neglect, and financial abuse
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Family Violence, Abuse and
Neglect
• Clinical manifestations
– Physical injuries
• Multiple injuries or injuries that are not well explained
• Common injuries include bruises, lacerations,
fracutes, head injuries
– Psychologic manifestations
• Anxiety, insomnia, vague GI complaints
– Usually do not identify abuser
– Neglect may manifest as poor hygiene,
dehydration, inattention to known medical needs
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•
Family Violence, Abuse and
Neglect
Assessment
– Acute awareness for signs of possible abuse/neglect
– Question patient in private, away from possible abuser
– Careful documentation
• May include quotations and photographs - may be used in
legal proceedings
• Management
– If abuse or neglect is suspected, primary concern is for
the safety of patient
– Multidisciplinary
• MD, RN, social worker, authorities
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Family Violence, Abuse and
Neglect
• Mandatory reporting laws
– If child or elder abuse is SUSPECTED, health
care workers must report suspicion to Child or
Adult Protective Services
– Proof is not required
– If report made in good faith, no criminal or civil
liability against HCW
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