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COMPREHENSIVE PHASE
HANDOUTS
EMERGENCY NURSING
Prepared By: PROF. LORELIE POMENTIL
NOV 2023 Philippine Nurse Licensure Examination Review
I.ISSUES IN EMERGENCY NURSING CARE illnesses and injuries to ensure that patients most
1.
Level Resuscitation
2.
1
3.
4. Level Emergent
2
II. PRINCIPLES OF EMERGENCY CARE
 By definition, ____________________ is Level Urgent
care that must be rendered without 3
____________. In an ED, several patients Level Less Urgent
with diverse health problems – some life- 4
threatening, some not – may present to the
ED simultaneously. One of the first Level Non-Urgent
principles of Emergency care is 5
__________.
in need of care do not needlessly wait.
1. TRIAGE
The goal of all TRIAGE is
- French word:
______________________ and
- Meaning:
_________________ preferably under
- Triage is used to sort patients into groups
______________.
based on the severity of their health
***EXERCISE
problems and the immediacy with which
1. First principle of emergency care –
these problems must be treated.
2. Triage means –
ED Triage Vs. FIELD Triage
3. Directs all available resources to most
 Routine Triage – directs
critical pt –
______________________ to the patients
4. Scarce resources used to benefit most
who are_________________ , regardless
people possible –
potential outcome.
5. 3 categories of routine triage –
 Field Triage (Reverse Triage) -
6. ESI considers these 2 factors –
______________ must be used to benefit
7. ESI Level if pt does not require any
the _____________ possible. (Hospital
resources to be stabilized -
triage during a disaster)
8. Guide how frequently patients must be
 Routine Triage
reassessed –
Three Categories:
9. Pt must receive continuous nursing
1. Emergent
surveillance -
2. Urgent
10. Reassessed q1H –
3. Non-urgent
5-Level Triage
2. Assess and Intervene
A. Emergency Severity Index (ESI)
A systematic approach to effectively
- ESI considers factors: acuity and
establishing and treating health priorities is the
resource
Primary survey and Secondary survey
ESI Level 1 approach.
 PRIMARY SURVEY
ESI Level 2
• Purpose: stabilize Life-threatening
ESI Level 3 conditions
• follow ABCDE method
ESI Level 4 A-
ESI Level 5 B-
C-
D-
E–
I. Airway
TRIAGE is an advanced skill. Emergency nurses • Airway Obstruction
spend many hours learning to classify different

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 a. Partial obstruction
b. Complete obstruction
Causes:
3 most common causes:
Other causes:
-aspiration of foreign objects
-trauma
-inhalation of chemical burns
A. aspiration of foreign objects
- Universal Distress Signal
- Cannot speak, breath, or cough
- Chocking, apprehensive appearance,
refusing to lie flat, inspiratory and
expiratory stridor, labored breathing
- Use of accessory muscles and flaring
nostrils
- Increased anxiety, restlessness, confusion
- Cyanosis and dec. LOC (late sign)
 Management: OPEN AIRWAY
1. Partial obstruction – pt can breath and
cough spontaneously
mgt: encourage pt to
2. Complete Airway Obstruction
mgt: Reposition the pt’s head
a.
b.
- Assess pt for breathing by watching for
chest movement and listening and feeling
for air movement
ESTABLISHING AN AIRWAY
1. Oropharyngeal airway
- circular tubelike plastic device
- inserted over the back of the tongue into
the lower posterior pharynx
- for pt:
- purpose: prevents the tongue from falling
back causing obstruction in airway; also allows
suctioning of secretions
2. Nasopharyngeal airway
- provides the same airway access but
inserted in the nares
- a nasopharyngeal airway should be tried if
a pt does not tolerate OP
 Quality & Safety Nursing Alert
In case of potential facial trauma or basal
skull fracture, the nasopharyngeal airway should
not be used because it could enter the brain cavity
instead of the pharynx.
3. Endotracheal Intubation
• Purpose
• Indications:
- 3. Universal Distress Signal in foreign body
- aspiration
- 4. Maneuver to open airway if Cervical injury is
- suspected
- 5. Used for pt’s breathing spontaneously but is
II. BREATHING
- provide adequate ventilation
- Pt’s who have experienced trauma must have
the cervical spine protected and chest injuries
assessed first, immediately after securing airway
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III. Circulation
- Any heart problem is a circulatory problem
3 classifications of Shock
A. Hypovolemic shock -
B. Cardiogenic Shock –
C. Distributive Shock -
A. Hypovolemic shock
 Assessment:
-
-
-
-
-
 Mgt
The goals of the emergency management:
1.
2.
3.
 The goals of the emergency management:
1. Control the Bleeding - stopping the bleeding is
essential to the care and survival of patients in an
emergency or disaster situation
2. Maintain adequate circulating blood volume by
– establish IV line for fluid replacement
3. Prevent Shock
– pt is maintained in the shock position
 Quality and Safe Nursing Alert
The infusion rate is determined by
______________________ the and the clinical
evidence of ___________. Any blood replacement
therapy should be given via __________ when
possible, because administration of large amounts
of blood that has been refrigerated has a core
cooling effect that may lead to ___________ and
_______________.
IV. Disability
- Determine neurologic disability
V. Exposure
- Undress the pt ___________ and
_____________ so that any wounds or
areas of injury are identified.
- To assess wounds and injuries immediately
***EXERCISE
1. It is the purpose of Primary survey
2. Leads to permanent brain damage and
death within 3-5 mins
unconscious
6. Used to establish and maintain the airway in
patients with respiratory insufficiency or
hypoxia
7. 3 classifications of Shock
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 8. Upper most priority during hypovolemic
shock  Risk factors for Heat Stroke:
9. shock position 1.
10. Fluid of Choice for fluid replacement 2.
3.
SECONDARY SURVEY 4.
- Complete health history  Assessment
- Head-to-toe assessment (includes - Profound central nervous system (CNS)
reassessment of airway, breathing and VS) dysfunction, manifested by: confusion,
- Diagnostic and Lab testing delirium, bizarre behavior, coma, seizure
- Application of monitoring devices (ECG, - Elevated body temperature: 40.6 deg cel or
arterial lines, urinary cath) higher
- Splinting of suspected fractures - Hot, dry skin usually anhidrosis
- Cleansing, closure and dressing wounds - Hypotension, tachycardia, tachypnea
- Performance of other necessary
interventions based on the pt’s condition  Management
Main goal:
I. ENVIRONMENTAL EMERGENCIES 1.
1.
Heat-induced illnesses 2.
2.
Hypothermia Methods:
3.
Drowning - Cool sheets and towels: continuous
4.
Snakebites sponging
I. Heat-induced illnesses - Cooling blankets
- Caused by prolonged exposure to - Immersion of the pt in a cold water bath
environmental heat leading to loss of electrolytes During cooling procedure:
- An electric fan is positioned so that it blows
on the pt: faster dissipation of heat by
_________ & __________
- Pt temp is constantly monitored with a
thermostat placed in the ________ ,
__________ and ________ to evaluate core
temperature
- Cooling process should stop at ______ in
order to avoid ____________

II. Hypothermia
A. HEAT CRAMPS - A condition in which the core (internal)
Has 3 cardinal manifestation: body temperature is ____ or less
1. - Emergency and life-threatening
2.
3.  Management
Management:
1.
2.
3.
4.
B. HEAT EXHAUSTION
Exhibit:
1.
2.  REWARMING
3. 2 Rewarming methods
4. 1. Active internal (core) rewarming method
5. - for ___________ to ___________
6. hypothermia (less than 28˚c to 32.2 ˚c)
7. • Includes:
Management: - Cardiopulmonary bypass
1. - Warm fluid administration
2. - Warmed Humidified Oxygen by Ventilator
3. - Warmed peritoneal lavage
C. HEAT STROKE • Monitoring for VeFib as the pt’s temp
- Most serious heat induced illness increase from 31 ˚c to 32 ˚c is essential.
- Acute medical emergency 2. Passive – Active external rewarming method
- Caused by failure of the heat-regulating - for mild hypothermia (32.2˚c to 35˚c)
mechanisms of the body • Includes:
- Associated with dehydration

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 a. Over –the-bed heaters (passive –
external) increase blood flow to the
acidotic, anaerobic extremities
b. Forced-air warming blankets (active –
external)
- WOF: extremity burn, pt may not have
effective sensation to feel burn
III. Nonfatal Drowning
- Survival for at least 24 hrs after submersion
that caused a respiratory arrest
- The majority of drowning events occur in
________, ________ and ________
 Prevention
1. Avoiding rip currents offshore
2. Surrounding the pool with fencing
3. Self-latching/closing gate
4. Providing swimming lessons
5. Personal floatation device
*_______________________ is still the best
prevention measure
 Major Complications
- After resuscitation:
- Pulmonary injury depend on the type of
fluid aspirated
• Freshwater –
• Salt-water –
 Management
1. The factor with the greatest influence on
survival:
2. Treatment goal:
3. Rectal probe
4. Indwelling FBC
5. ECG monitoring
6. NGT for decompression –
IV. SNAKEBITES
- venomous snakebites are medical
emergencies
- The most common site is the:
• Envenomation –
 Classic clinical signs of envenomation:
 Management
 Initial first aid at the site:
- have the person lie down
- remove constrictive items( ring)
- provide warmth
- cleansing the wound
- covering the wound with a light sterile
dressing
- Immobilize below the level of the heart
 Management
- no one specific protocol for tx of snakebite
- Generally NOT used during the acute stage
a. ice, tourniquets,
b. heparin
c. corticosteroids
- Typically, pt is observed closely for at least
6 hrs.
- The pt is never left unatteneded
-
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 Antivenin – antitoxin manufactured from
the snake venom and used to treat
snakebites
- Assessment of progressive s & sx is
essential before the administration of
antivenin
- Most effective given within ______ post bite
- Serum sickness is a type of hypersensitivity
response: before administering antivenin
and every 15mins thereafter, the
circumference of the affected part is
measured
- Can be given ___ or ____
- Depending on the severity of the snakebite,
antivenin is diluted in 500 or 1000 mL NSS
- Infusion is started slow then the rate is
increased after _______ if no reaction
- The total dose should be infused during the
first 4-6 hrs after the bite.
- The initial dose is repeated until sx decrease
- There is NO limit to the number of antivenin
vials that can be given.
***EXERCISE
1. Heat induced illness due to exposure to envi
temp >38.8˚c
2. Most serious heat induced illness
3. Optimal method for cooling
4. Hypothermia: core body temperature is
____ or less
5. Forced-air warming blankets is what type of
rewarming method
6. The best prevention measure of drowning
7. Injection of a poisonous material by sting,
spine, bite or other means
8. Most common site of snakebite
9. Antivenin Most effective given within
10. Antivenin can be given via
DISASTER NURSING
 TRIAGE CATEGORIES
In a disaster, when HCP are faced with a large
number of casualties, the fundamental principle
guiding resource allocation is to do good for the
greatest number of people
The North Atlantic Treaty Organization
(NATO) Triage system
- Most widely used triage category
- Consist of four colors: red, yellow, green
and blue, each color signifies a different
level of priority
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