EMERGENCY NURSING

3. ADPIE
PRIORITIZATION:
● PRIMARY SURVEY = stabilize the condition
1. ABCDs:
of the patient
● AIRWAY
⮚ AIRWAY
❒ Increased/decreased RR
✔ Head tilt Chin Lift maneuver
❒ RR pattern
− to maintain airway
● BREATHING patency
❒ Level of oxygen ● Make sure the patient has no
spinal cord injury.
❖ Check pulse oximeter
✔ Jaw Thrust
⮚ NORMAL: 95-100%
− To maintain airway
⮚ 90% = CONTINUE MONITORING
patency
the pt
⮚ Below 90% = NOTIFY physician ⮚ BREATHING
⮚ 70% or below = prepare for ✔ Observe chest and abdomen
INTUBATION
✔ Feel breathing pattern through
❖ Provide assistance in preparing for
nose
intubation to the doctor
⮚ CIRCULATION
❖ Nurses can give supplemental oxygen
(2 L/min) ✔ Check for pulse

● CIRCULATION ● Carotid pulse = for cardiac

arrest patients
❒ Blood and Fluid loss
− determine if there is blood
● DISABILITY
flow through the brain
❒ Level of Consciousness ● Brachial pulse = for INFANTS
❖ CHECK GCS (>1 year old)
− Determine if there is blood
❒ How to check for Level of Orientation?
flow through the brain
❖ Ask patient for Time Place and
● 5 minutes of without oxygen =
Person.
irreversible brain damage
(permanent)
2. MASLOW’s Hierarchy of Needs
(IN ORDER!!!!!!!!!!!!!!!!!!) “PSLSS” ✔ Check for blood and fluid loss
A. Physiologic needs (BASIC needs)
“OWFSCSPS” ⮚ DISABILITY
a. Oxygen
✔ Neurologic Status (GCS)
b. Water
c. food ● 15 = NORMAL
d. shelter
e. clothing ● 8 = COMA (Unconscious,
f. sleep and rest responsive)
g. freedom of pain
h. sex ● 3 = DEEP COMA (Unconscious,
B. Safety and Security (Freedom from unresponsive)
harm and injury) ✔ How to check for Level of
C. Love/belongingness (social decision
and companionship) Orientation?
D. Self-Esteem (belief on oneself)
E. Self-actualization (SATISFACTION)
 ● Ask patient for Time Place and MOTOR away from pain)
Person. RESPONSE
✔ FLAT EEG = BEST clinical
3 = ABNORMAL FLEXION
indicator of death of the patient
(DECORTICATE = Fetal position)

NEUROLOGICAL ASSESSMENT 2 = EXTENSION

Glasgow Coma Scale (GCS) (DECEREBRATE)
● MILD = 13-15
1 = NONE (no response)
● MODERATE = 9-12

● SEVERE = 3-8
SHOCK
● Deficient in circulating blood volume
BEHAVIOUR RESPONSE
● NURSING MGT: GIVE IV FLUIDS
4 = SPONTANEOUS ● Symptoms: HYPO TACHY TACHY
a. Hypotension
3 = TO SOUND (Respond on b. Tachycardia
EYE OPENING verbal command) c. Tachypnea
RESPONSE ● TYPES OF SHOCK:
2 = TO PRESSURE (respond on a. SEPTIC SHOCK
pain) ❖ Cause:
o INFECTION
1 = NONE (absent) ❖ Classical Symptom:
o FEVER
❖ NURSING MGT:
o ANTIBIOTICS (Penicillin)
5 = ORIENTED (answers b. ANAPHYLACTIC SHOCK
correctly) ❖ Cause:
o ALLERGY
4 = CONFUSED (answers not ❖ Classical Symptom:
relevant) o DOB (Difficulty of Breathing)
VERBAL
RESPONSE ❖ NURSING MGT:
3 = WORDS (out of topic) o EPINEPHRINE
o BRONCHODILATORS
2 = SOUND (gibberish) o Prepare ETT and tracheostomy
ties at bedside
c. CARDIOGENIC SHOCK
1 = NONE (no response)
❖ Cause:
o MI
o CHF
o OTHER HEART PROBLEMS
6 = OBEYS COMMAND ❖ Classical Symptom:
o CHEST PAIN
5 = LOCALISING (moves on
❖ NURSING MGT:
localized pain)
o MORPHINE

4 = NORMAL FLEXION (moves − Check first RESPIRATION

RATE!
 − Morphine can cause
respiratory depression.
− ANTIDOTE FOR
MORPHINE: NARCAN
(NALOXONE)
d. NEUROGENIC SHOCK
❖ Cause:
o SPINAL CORD INJURY
❖ Classical Symptom:
o BRADYCARDIA
❖ NURSING MGT:
o SURGERY
e. HYPOVOLEMIC SHOCK
❖ Cause:
o BLOOD LOSS
o FLUID LOSS
❖ Classical Symptom:
o HYPOTENSION
o TACHYCARDIA
o TACHYPNEA
❖ NURSING MGT:
o BLOOD TRANSFUSION (BEST)
o GIVE IV FLUIDS
o GIVE ALBUMIN (it is a VOLUME
EXPANDER)