Care of the clients with life threatening conditions,

acutely ill, multi-organ problems high acuity and

emergency situation.
NCM 117
Objectives
At the end of the topic, the students will be able to:

•Demonstrate knowledge, clinical and technical skills and decision-making

capabilities pertinent to the management of various emergency conditions
•Develop a systemic approach to the assessment and treatment of the acutely
ill/injured patient
•Develop appropriate triage skills
•Describe emergency care as a collaborative holistic approach that includes the
patient the family and significant others .
•Discuss priority emergency measures instituted for any patient with an emergency
conditions.
Emergency Nursing

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Emergency Nursing

• Emergency Nursing is a nursing

specialty in which nurses care for
patients in the emergency or critical
phase of their illness or injury.

• While this is common to many nursing

specialties, the key difference is that an
emergency nurse is skilled at dealing
with people in the phase when a
diagnosis has not been made and the
cause of the problem is not known.
Scope of Practice
The scope of emergency nursing
practice involves:
• Assessment
• Analysis
• Nursing diagnosis
• Outcome identification
• Planning
• Implementation of interventions
• Evaluation
Scope of Practice

• These are directed towards human responses to

perceived, actual or potential, sudden or urgent, physical
or psychosocial problems that are primarily episodic or
acute and which occur in a variety of settings.

• These may require minimal care to life-support measures;

patient, family, and significant other education;
appropriate referral and discharge planning; and
knowledge of legal implications.
ISSUES IN EMERGENCY NURSING CARE

legal issues
occupational health and safety risks
providing holistic care in the context of a fast-paced,
technology-driven environment
Functions of the Emergency Nurse

• Triage and prioritization

• Emergency operations preparedness
• Stabilization and resuscitation
• Crisis intervention for unique patient populations such as
sexual assault survivors
• Provision of care in uncontrolled or unpredictable
environments
• Consistency as much as possible across the continuum of
care
Areas within the emergency department
Pre-hospital care
Methods of pre-hospital transport
 Pre-hospital care
Pre-hospital environment: Scene assessment

CASMEET
❖ Call sign
❖ Age of patient
❖ Sex of patient
❖ Mechanism of injury or mode of illness
❖ Examination carried out
❖ Estimated time of arrival
Emergency
Assessment
NCM 117
PRINCIPLES OF EMERGENCY NURSING

14
Triage

• Triage is a French word meaning “sorting, selection,

choice”. It came from the French verb “trier” meaning
“to sort, select, choose” and has been used in English
since 1727 to indicate the action of assorting according
to quality.

• Triage – the process of sorting people based on their need

for immediate medical treatment as compared to their
chance of benefiting from such care. Triage is the process
of prioritizing treatment during mass casualty events.
Triage
Aims:
• To ensure that patients are treated in the order of their
clinical urgency
• To ensure that treatment is appropriate and timely
• To allocate the patient to the most appropriate assessment
and treatment area and avoid congestion
• To provide ongoing assessment of patients
• To provide information to patients and families regarding
services expected care and waiting times
• To contribute information that helps to define departmental
acuity
THE TRIAGE PROCESS

Assign Triage Level

Five level emergency severity index ( ESI)
Five level emergency severity index (
ESI)
ORANGE
CTAS 5 LEVEL TRIAGE
RESUSCITATION / IMMEDIATE

Conditions that are threats to life or limb ( or

imminent risk of deteriorations
CASE EXAMPLE

• 57 year old Male

• Severe chest pain and shortness of breath
• Collapse to the ground while playing lawn
tennis
• Vital signs absent

Cardiac arrest
Conditions that are a potential threat to life limb
or function requiring rapid intervention rage
CASE EXAMPLE
▪52-year-old male
▪reported a one-hour history of heavy central substernal
chest pain which has now resolved
▪vital signs are R20 HR 68 BP 130/70

Chest pain cardiac features

Conditions that could potentially progress to a serious
problem requiring emergency intervention. May be
associated with significant discomfort or affecting ability
to function at work or activities of daily living .
CASE EXAMPLE
62-year-old male
Claiming pain worsening to 5/10 for over 12 hours
vital signs stable heart rate of 100 and temperature of
37.6 degrees centigrade
Conditions that relates to patient age , This stress
or potential for deterioration or complications
which would benefit from interventions or
reassurance within one to two hours .
CASE EXAMPLE

12 year old
3 CM laceration on right palm cut with a kitchen knife
not actively bleeding pain 4/10
vital signs normal
requires suture

laceration
Conditions that may be acute but non urgent as well as
conditions which may be part of a chronic problem with
or without evidence of deterioration the investigation or
interventions for some of these illnesses or injuries could
be delayed or even referred to other areas of the hospital
or health care system .
CASE EXAMPLE

A 25-year-old otherwise healthy patient presents

requesting a dressing change
no other issues identified
Emergency Assessment

1. Primary Survey
• A – airway
• B – breathing
• C – circulation
• D – disability
• E – exposure / environment
2
FIRST MODIFIERS

Exposure
AIRWAY ASSESSMENT AND MANAGEMENT

Causes of airway problems

Airway assessment

Airway equipment

Definitive airway
 ASSESSMENT OF BREATHING
Structured assessment

Respiratory rate RIPPAS

Inspection
Palpation
Percussion
Auscultation
Saturations
RESPIRATORY DISTRESS