Scope and Practice of Emergency Nursing

Emergency management
• 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 in crisis
situations
Characteristics of Emergency Departments:
• Chaotic and rapidly changing
• Safety net by providing services to insured and uninsured seeking
immediate help
• Fast paced
• Chaotic & many distractions = room for errors
• Variety of acuity levels
• Often over crowded
• May be temporary bridge to establishing relationship w/care provider
Most common complaints in ED:

• Chest pain
• Abdominal pain
• Fever
• Headache
Characteristics of ED Nurses

• Dislike routine
• Broader knowledge of disease processes
• Broader client base from young to old
• Comfortable treating patients anyway
• Able to wear many hats – cardio, peds, phsych, trauma
Interdisciplinary Team
• Prehospital Care Providers = EMT/paramedics = valuable source for
data
• Support / Ancillary Staff = techs (radiology, lab, etc) + social workers
+ other therapists (respiratory, physical, etc) + case managers
Hand off communication
process for patient safety = standardized approach

• Situation (why in ED)

• Brief medical hx
• Assessment and dx
• Transmission based precautions needed
• Interventions
• Response to interventions
• Requires efficient communication skill and respectful negotiation
Principles of ED Nursing
• Staff safety concerns => focus on potential for transmission of disease &
personal safety (violent pt, aggressive, agitated, etc) → standard precautions
at all times + recognizing hazardous conditions and behaving accordingly →
plan options for violence, s.a. security

• Most common pt errors = fall risk & patient identification

Types of Emergency
• The types of emergencies indicated and their definitions, with the
exception of terrorism, were selected in accordance with the categories
for which the Centers for Disease Control and Prevention (CDC) provide
specific emergency response and prevention information.
A. Bioterrorism - refers to the deliberate release of viruses, bacteria, or
other agents used to cause illness or death in people, animals, or plants.
These agents can be spread through the air, water, or in food.
B. Chemical emergencies - occur when a hazardous chemical is released
and the release has the potential for harming people’s health. Chemical
releases can be unintentional such as an industrial accident, or
intentional such as in the case of a terrorist attack.
C. Mass Casualties - refer to incidents such as fires, explosions, mass
transit accidents such as train crashes or bridge collapses that cause
numerous deaths and injuries.
D. Natural Disasters - refer to such natural occurrences as earthquakes,
extreme heat, floods, hurricanes, landslides and mudslides, tornadoes,
tsunamis, volcanoes, wildfires, and winter weather.
E. Outbreaks - refer to flu epidemics, viruses, or other contagious
diseases; also could include food-borne outbreaks such as salmonella or
E. coli.
F. Radiation - emergency could be a nuclear power plant accident or a
terrorist event such as a dirty bomb or nuclear attack, which would
expose people to significantly higher levels of radiation than are typical
in daily life, leading to health problems such as cancer or even death.
G. Terrorism - refers to a deliberate act of murder and destruction which
disrupts infrastructure and is directed towards civilians with the aim of
meeting political ends.
Triage
• Triage sorts patients by hierarchy based on the severity of health problems
and the immediacy with which these problems must be treated
• 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, regardless of potential outcome
• “trier”- to sort
• To sort patients in groups based on the severity of their health problem and
the immediacy with which these problems must be addressed
Use of nursing process
• assess and dx
o accurate and quick assessments needed
o sorting information
o planning and implementing

•  acuity → quickest care

o  acuity has to wait
• RN as “gatekeeper”
o Independently perform triage
o Following protocols = Rapid dx and tx
▪ Administration of Oxygen
▪ Cardiac monitoring
▪ IV ACCESS
▪ Collecting samples (urine, blood, etc) before seeing physician
▪ Triage nurse initiation for lab work or dx tests before pt seen by physician
o Initiation of care while pt on stretcher in hallway of overcrowded ED
• Check on waiting patients
o To see if anything changes, develop therapeutic relationship, vital signs change,
etc.
▪ Obligation to profession and community
Three tiers of triage
• Emergent = condition poses immediate threat to life or limb

• Urgent = pt should be treated quickly but no immediate threat to life at

this moment → pt must be reassessed d/t changes

• Nonurgent = can tolerate waiting w/o significant risk of deterioration =

sprains, strains, simple factures, “colds,” rashes
Tier level Examples
Emergent = life threatening Respiratory distress
Chest pain with diaphoresis
Active hemorrhage
Unstable vitals
Urgent = quick tx but not life threatening Severe abdominal pain
Renal colic
Displaced or multiple fractures
Complex or multiple soft tissue injuries
New onset respiratory infections, esp in older adults
w/suspected pneumonia
Nonurgent Skin rash
Strains and sprains
“colds”
Simple fractures
• Emergency Severity Index = 5 tier system from level 1 (=emergent) to
level 5 (=nonurgent)

• Rapid, reliable, clinically pertinent

• Uses both acuity and prediction of resources to categorize priorities
start
• Simple Triage And Rapid Treatment
• (START) is a triage method used by first responders to quickly classify
victims during a mass casualty incident (MCI) based on the severity of
their injury.
start
4 things to think about…
• Ability to follow directions and walk
• Respiratory effort
• Pulses/perfusion
• Mental status
Care of Patient
• Maintaining privacy and dignity
o Double gown pt + sheet or blanket
• Maintaining confidentiality
o Keeping voice low when discussing
• Nurse responsible for follow up care
o Medication administration
o Specimen collection
o Assistance w/bedside procedures
o Discharge planning
o What to delegate to techs
• May need to reassess and reprioritize whenever necessary
• Awareness of cultural values
o Language barriers
o Religious prohibitions
▪ Jehovah’s witnesses cannot have blood transfusions
• Patient disposition = conclusion of work up by physician
o Admit to facility or different facility
▪ Usually, physician call but often in collaboration w/nurse
o Communicate with next step
o Head injury w/LOC → someone stays with pt for 1st 12-24h to be sure
no signs of neuro deterioration
o Potential risk to pt w/actual or suspected domestic violence
▪ May admit pt to hospital if home unsafe
Are we ready
What is the Universal First Aid symbol?

A B C
2. What is the symbol for Red Cross?

A B
3. It is an immediate treatment or care given to
someone suffering from an injury or illness until
more advanced care is accessed or they recover.
4. Some organizations may make use of the Star
of Life, although this is usually reserved for use by
ambulance services. What is the symbol used.

A B C
5. Give at least 3 things that should be
present in the First Aid Kit
 Prequiz:
True or False?
•After an accident, immediately move the victim to a comfortable
position.
•If a person is bleeding, use a tourniquet.
•Signs of a heart attack include shortness of breath, anxiety, and
perspiration.
•All burns can be treated with first aid alone; no emergency
medical attention is necessary.
Four Basic Rules

1.2.Call
Bring
forhelp
helptoimmediately
the victim
4.3.Do no further
Check harm
the ABCs
DEFINITION
• First Aid is a system of assessments and interventions that can
be performed by a bystander (or by the victim) with minimal or
no medical equipment.
• A first aid provider is defined as someone with formal training in
first aid, emergency care, or medicine who provides first aid.
Aims of First Aid
4 Ps
• Preserve Life:
To save lives and minimize the threat of death.
• Prevent Further Harm:
Moving the patient away from any cause of harm and applying first
aid techniques to prevent worsening of the condition.
• Promote Recovery:
First aid also involves trying to start the recovery process from the
illness or injury and in some cases might involve completing a treatment.
Levels of Training
• First Aider
• First Responder
• Emergency Medical Technician – Basic
• Emergency Medical Technician – Intermediate
• Emergency Medical Technician – Paramedic

Specializations
• Dive Medical Technician
• Critical Care Paramedic
• Flight Paramedic
• Combat Medic
Responsibilities as a First Aider
• Assess the situation quickly and safely and summon appropriate help
• Protect casualties and others at the scene from possible danger
• To identify, as far as possible, the nature of illness or injury affecting
casualty.
• To give each casualty early and appropriate treatment, treating the
most serious condition first.
Responsibilities as a First Aider
• To arrange for the casualty’s removal to hospital or into the care of a
doctor.
• To remain with a casualty until appropriate care is available.
• To report your observations to those taking care of the casualty, and to
give further assistance if required.
PRIORITY OF CASUALTIES
• Save the conscious casualties before the unconscious ones as they
have a higher chance of recovery.
• Save the young before the old.
• Do not jeopardize your own life while rendering First Aid. In the event
of immediate danger, get out of site immediately.
Remember: One of your aims is to preserve life, and not endanger your
own in the process of rendering First Aid.
Responding to Emergencies
REACT to an Emergency
• Recognize an emergency.
❖ Scream, panic; seriously ill or injured person; victim or bystander
agitated or threatening.
❖Suspicious environment; collision or stopped vehicle; environmental
hazard
❖Remain calm; stay aware of your own safety
Responding to Emergencies
• Environment. Size up the scene from a safe distance, common hazards
includes:
❖Blood and body fluids
❖Traffic
❖Fire or Smoke
❖Wet, icy or unstable surfaces or structure
❖Downed electrical wires
❖Hazardous material, chemicals and gases
❖Open water, strong currents
❖Confined space
Responding to Emergencies
▪ Size up the victim(s):
✓How many?
✓What is their general condition? Are they moving?
✓Try to identify cause of illness or injury.
Activate EMS now if the scene is dangerous or if there is an obvious life-
threatening injury or illness.
Tip: Before you enter an emergency scene, consider how you will exit.
Responding to Emergencies
• Assess the victim.
❖Go to the victim’s side and assess respnse and breathing
❖Look for serious illness or injury.
Responding to Emergencies
• Call for help.

❖If the victim has a life-threatening condition, get help.

❖Shout for help, call the emergency response number.
Responding to Emergencies
• Treat the victim.
❖Treat the life-threatening conditions first.
❑If unresponsive, call the emergency response team and assess
breathing.
❑If no breathing or only gasping, begin CPR (Compression-only CPR
in untrained).
❑If severe bleeding, control with direct pressure
• Treat the victim in the position found. Only move the victim if danger
or need to reposition for essential care or position of comfort.
Introduction

• One of the most important skills you will develop is the ability to assess
a patient.
• Identify your patient’s problem(s).
• Set your care priorities.
• Develop a patient care plan.
• Execute your plan.
Sick Versus Not Sick

• Determine whether the patient is sick or not sick.

• If the patient is sick, determine how sick.
• Every time you assess a patient:
• Qualify whether your patient is sick or not sick
• Quantify how sick the patient is
Establishing the Field Impression

• A determination of what you think is the patient’s current problem

• You must be able to communicate and ask the right questions.
• Be a “detective.”
Establishing the Field Impression

• The process must be organized and systematic but still flexible.

• Know when to expand your questioning.
• Know when to focus your questioning.
Medical Versus Trauma

• Medical patients
• Identify chief complaint and sift through medical history.
• Trauma patients
• Medical history may have less impact
• Requires a modified approach
Scene Safety

• Crash-and-rescue scenes often include multiple risks.

• Wear a high-visibility public safety vest.
• Consider specialty reflective gloves, coats, and boots.

Courtesy of Anthony Caliguire, NREMT-P

© Adam Alberti, NJFirePictures.com

Scene Safety

• Ensure that your team can safely gain access to the scene and the
patient.
• Establish a safe perimeter to keep bystanders out of harm’s way.
Scene Safety
• Be wary of toxic substances and toxic
environments.
• Proper body and respiratory protection is a
must.

Courtesy of Tempe Fire Department

Scene Safety
• Potential crime scenes
• Law enforcement should enter
first.
• Formulate an escape plan.
• Be aware of violence from
bystanders.
• Patients who abuse
methamphetamines can be a large © Paul Chiasson, CP/AP Photos

threat.
Scene Safety
• Risks related to the environment
include:
• Unstable surfaces
• Snow and ice
• Rain
• Consider the stability of the
structures around you.
Courtesy of James Tourtellotte/U.S. Customs & Border Control
Scene Safety

• Ensure safety of the patient and bystanders next.

• When the environment is unfriendly perform assessment, address
threats, and move the patient as quickly as possible.
MEDICAL EMERGENCIES
• Respiratory
• Cardiovascular
• Neurological
• Environmental
• Allergies
• Bites and Stings
• Poisoning
Respiratory Emergencies
• Breathing Difficulty
• Assist with Inhaler if patient is a known asthmatic.
• Activate EMS
Cardiovascular Emergencies
• Chest Discomfort
• Often crushing or squeezing
• Does not change with each breath
• Pain in lower jaw, arms, back, abdomen, or neck
• Shortness of breath
• Treatment
• Administer Aspirin
• Activate EMS
Neurological Emergencies
• Seizures
• Do not restrain.
• Do not place any object between the patient’s teeth.
• Ensure open airway.
• Patient may be unresponsive for a short while after seizure.
Neurological Emergencies
• Stroke
• Weakness or paralysis on one side
• Difficulty speaking
• Salivation
• Decreased level of consciousness
• Headache
• Seizure
• Treatment
• Transport immediately
• Place paralyzed side with padding
• Consider head support
Allergies
• Allergen Categories
• Insect bites and stings
• Medications
• Plants
• Food
• Chemicals
• Anaphylaxis
• Extreme allergic reaction
• Involves multiple organs
• Can rapidly result in death
• Most common signs:
• Wheezing
• Urticaria (hives)
Allergies
Signs and Symptoms
• Widespread urticaria
• Wheals
• Swelling of the lips and tongue
• Chest tightness and coughing
• Abdominal cramps
• Flushing, itching, or burning skin
• Warm, tingling feeling in the face, mouth, chest, feet, hands
• Sneezing or itchy, runny nose
• Rapid, labored, or noisy respirations
Bites and Stings
• Death from insect stings outnumber those from snakebites.
• Venom is injected through stinging organ.
• Some insects and ants can sting repeatedly.
• Signs and symptoms:
• Sudden pain, swelling, and redness at site
• Itching and sometimes a wheal
• Sometimes dramatic swelling
Removing Stingers
Poisoning
• Poison - Any substance whose chemical action can damage body
structures or impair body functions
• Ingestion – by mouth
• Inhalation – by breathing
• Injection – by animal bites, stings, syringes
• Absorption – by skin contact
Poisoning
• Treatment
• Ask the patient if conscious
• Bag the substance in question
• Activate EMS
Poison Centers
• Poison Centers can provide a rundown on a poison’s:
• Ingestion
• Toxic potential
• Steps to negate effects
• Never hesitate to call!
• +63.2.5241078 UP NPMCC
Environmental Emergencies
HEAT CRAMPS
• Painful muscle spasms
• Remove the patient from hot environment.
• Rest the cramping muscle.
• Replace fluids by mouth.
• If cramps persist, transport the patient to hospital.
Environmental Emergencies
HEAT EXHAUSTION
• Dizziness, weakness, or fainting
• Onset while working hard or exercising in hot environment
• In older people and young, onset may occur while at rest in hot, humid,
and poorly ventilated areas.
• Cold, clammy skin
• Dry tongue and thirst
• Patients usually have normal vital signs, but pulse can increase and blood
pressure can decrease.
• Normal or slightly elevated body temperature
Environmental Emergencies
HEAT EXHAUSTION
• Treatment
• Remove extra clothing and remove from hot environment.
• Have patient lie down and elevate legs.
• If patient is alert, give water slowly.
• Be prepared to transport.
Environmental Emergencies
HEAT STROKE
• Hot, dry, flushed skin
• Change in behavior leading to unresponsiveness
• Pulse rate is rapid, then slows.
• Blood pressure drops.
• Death can occur if the patient is not treated.
Treatment
• Move patient out of the hot environment.
• Remove the patient’s clothing.
• Apply cold packs to the patient’s neck, armpits, and groin.
• Cover the patient with wet towels or sheets.
• Aggressively fan the patient.
• Activate EMS
TRAUMA EMERGENCIES
• Mechanism of Injury
• Muscoloskeletal
• Head and Spine
• Eye
Mechanism of Injury
• Force may be applied in several ways:

Direct blow High-energy

Twisting force
Indirect force injury
Types of Musculoskeletal Injuries
• Fracture
• Broken bone
• Dislocation
• Disruption of a joint
• Sprain
• Joint injury with tearing of ligaments
• Strain
• Stretching or tearing of a muscle
Musculoskeletal Injuries
• Signs and Symptoms
• Marked deformity
• Swelling
• Pain
• Tenderness on palpation
• Virtually complete loss of joint function
• Numbness or impaired circulation to the limb and digit
• Treatment
• Splint or immobilize as found
• Activate EMS
 Muscle Cramps
• Stretch the muscle and apply heat or cold (preferably heat).
• Cramps from lack of salt and water: Stretch the muscle, drink water and
increase salt intake
Fractures and Dislocations
• Support and immobilize the injured limb.
• Use a splint (if possible) in order to prevent movement of the
injured part.
• Arrange for casualty to be removed to hospital.
• In doubtful cases, always treat as for a fracture.
• Do not attempt to replace the bones.
splint
• A splint is a piece of medical equipment used to keep an injured body
part from moving and to protect it from any further damage.

• Splinting is often used to stabilize a broken bone while the injured person
is taken to the hospital for more advanced treatment. It can also be used
if you have a severe strain or sprain in one of your limbs.
What you’ll need for splinting an injury
The first thing you’ll need when making a splint is something rigid to
stabilize the fracture. Items you can use include:

•a rolled-up newspaper
•a heavy stick
•a board or plank
•a rolled-up towel
How to apply a splint
1. Attend to any bleeding
Attend to bleeding, if any, before you attempt to place the splint.
You can stop the bleeding by putting pressure directly on the
wound.
2. Apply padding
Then, apply a bandage, a square of gauze, or a piece of cloth.
Don’t try to move the body part that needs to be splinted. By
trying to realign a misshapen body part or broken bone, you may
accidentally cause more damage.
3. Place the splint
Carefully place the homemade splint so that it rests on the joint
above the injury and the joint below it.
For example, if you’re splinting a forearm, place the rigid support
item under the forearm. Then, tie or tape it to the arm just below the
wrist and above the elbow.
Avoid placing ties directly over the injured area. You should fasten
the splint tightly enough to hold the body part still, but not so
tightly that the ties will cut off the person’s circulation.
4. Watch for signs of decreased blood circulation or shock
Once the splinting is completed, you should check the areas around it
every few minutes for signs of decreased blood circulation.
If the extremities begin to appear pale, swollen, or tinged with blue,
loosen the ties that are holding the splint.
Post-accident swelling can make the splint too tight. While checking for
tightness, also feel for a pulse. If it’s faint, loosen the ties.
Sprain
• Support the joint in most comfortable position.
• P.R.I.C.E. (Protect, Rest, Ice, Compression, Elevation) treatment
• When a sprained ankle occurs outdoors, do not remove the shoe.
• If unsure whether there is a fracture, always assume it is one
Head and Spine Injuries
• Lacerations, contusions, hematomas to • Amnesia
scalp • Seizures
• Soft areas or depression upon palpation • Numbness or tingling in the
• Visible skull fractures or deformities extremities
• Ecchymosis around eyes and behind the • Irregular respirations
ear • Dizziness
• Clear or pink CSF leakage • Visual complaints
• Failure of pupils to respond to light • Combative or abnormal behavior
• Unequal pupils • Nausea or vomiting
• Loss of sensation and/or motor function
• Period of unconsciousness
Head and Spine Injuries
• Treatment
• Head and Cervical Spine Immobilization
• Treat any life threatening bleeding
• Activate EMS
Significant Mechanisms of Injury
• Motor vehicle crashes
• Pedestrian-motor vehicle collisions
• Falls
• Blunt or penetrating trauma
• Motorcycle crashes
• Hangings
• Driving accidents
• Recreational accidents
Characteristics of Bleeding

Capillary Venous Arterial

Blood oozes out and Blood is dark red and Blood is bright
is controlled easily. does not spurt. red and spurts.
Bleeding
• Stop the flow of blood
• Cover the wound
• Apply pressure
• If a body part has
been amputated,
put it on ice
Control of bleeding
Eye Injuries
• In a normal, uninjured eye, the entire circle of the iris should be visible.
• Pupils should be round, equal in size, react equally when exposed to
light.
• Both eyes should move in same direction when following a finger.
• Always note patient’s signs and symptoms including severity and
duration.
• Surgery/restoration of circulation to eye may need to be achieved in 30
minutes.
• Treat any life-threatening bleeding.
• Activate EMS.
SAFE EVACUATION OF THE CASUALTY FROM DANGER AREA

Remember! Never move a casualty with suspected spinal injury unless

assisted by medical personnel.

Exceptions:
• Life-threatening situation
• At a mass-casualty incident
• If the original position of the casualty prevents you from establishing and
ensuring a free airway

Proceed with extreme caution if you suspect a neck or spinal injury!

Firemans Carry
Lovers Carry
Assist to walk/Human crutch
Piggyback Carry
Dragging method
Lifting and Moving Lifts and Transfers
Mass-Casualty Incidents
• Incidents involving three or more patients
• Places high demand on available resources
• May require mutual aid response
You begin saving the
world
by saving one person
at a time.