RTRMF – BSN LEVEL 4 LECTURER: Mrs. Evelyn U.

Rances
NCM 118 BATCH TOPAZ

EMERGENCY NURSING
Almost or totally immobile, and
Stuporous unresponsive even to painful stimuli;
TOPIC OUTLINE reduced consciousness and diminished
1. Competencies for RN spontaneous movement.
2. Core Competencies Comatose / Abnormally deep sleep caused by illness
3. Critical Care Nursing Unconscious or injury. Characterized by absence of
4. Communication
spontaneous eye opening, response to
5. Core Knowledge Areas
6. Types of Prevention painful stimuli or vocalization.
7. Healthcare System and Policy
8. Professional Role and Development ii. Orientation to person, place, time, and events
9. Legal Issues in Emergency Nursing That’s why when you ask questions, masiring ka “anot imo
10. Ethical Issues
ngaran mano?” “maaram ka kun hain ka na lugar?”; pag
11. Emergency Nursing
12. 5 Levels of Acuity sumiring hiya na aadto ako ha balay, takay aadto hiya ha
ospital, that means the patient is disoriented to place.
COMPETENCIES FOR REGISTERED NURSES RESPONDING
iii. Glasgow Coma Scale Score
TO MASS CASUALTY INCIDENT
Glasgow Coma Scale Score
Governing Principle in MCI: Spontaneous 4
“To do the greatest good for the greatest number of Eye To verbal command 3
casualties”. In other words, if there is a number of casualties, Opening To pain 2
for example if there is a vehicular accident, there are plenty of No response 1
victims, following this principle, you do your best to perform Obeys to verbal command 6
interventions, to the different casualties, as fast as possible, so To painful stimuli 5
Motor Withdraws to painful stimuli 4
that you can cater a number of casualties in a certain time.
Response Assumes decorticate posture 3
Competencies – are complex combination of knowledge, Assumes decerebrate posture 2
skills, and abilities. No response 1
Oriented, Converses 5
CORE COMPETENCIES Best Disoriented/Confused 4
1. Critical Thinking Verbal Uses inappropriate words 3
- Sound knowledge base; flexibility and adaptability Response Makes incomprehensible sounds 2
are essential traits of a nurse. No response 1
- Requires risk taking, remain calm, rapidly assess Maximum Score 15
situations, consider options, address new
problems, preparedness to assume responsibility,
prioritize and delegate limited resources and iv. Scale for Grading Reflex Response
ability to triage situation No reflex / No response 0
Minimal activity / Hypoactive activity +1
2. Nursing Assessment Normal response +2
More active than normal +3
- Rapidly and accurately discern normal from
Maximum activity / Hyperactive activity +4
abnormal
- It must categorize assessment findings according
v. Pupillary size, equality, and reaction to light and
to acuity and age.
accommodation (PERRLA)
Two types:
a. Primary Assessment vi. Motor movement and strength of hand grip and
- Immediately identify any client problem that poses a pedal pulses
threat, immediate, or potential, to life limb or vision. So, you ask the patient to hold your hand and then the patient to
- Information gathered through objective data using squeeze your hand, that is part of your hand grip.
the “ABCD” mnemonics:
vii. Neurologic Assessment in Children Using the APVU
✓ A – Airway patency
Mnemonics
✓ B – Breathing
✓ C – Circulation A Alert Child is awake, alert, and need no
✓ D – Disability stimulus to respond to environment
P Pain Child requires a painful stimulus to
Neurologic Assessment
evoke a response
i. Level of Consciousness: V Verbal Child requires verbal stimulus to
elicit a response
Alert Quick, active, and keenly aware of the U Unresponsive Child is unresponsive to any applied
environment. stimulus
Lethargic Forgetful, drowsy, indifferent, apathetic,
or sluggish b. Secondary Assessment
Render insensitive to unpleasant or - A brief but thorough systematic assessment designed
Obtunded painful stimuli by reducing the level of to identify all injuries.
consciousness.

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RTRMF – BSN LEVEL 4 LECTURER: Mrs. Evelyn U. Rances
NCM 118 BATCH TOPAZ

That’s the time that you undress the patient, so when the patient ❖ General overview
is lying down on the bed in the emergency room you provide • Head to toe assessment
privacy. You undress the patient, why? Because you are trying to • Injuries that were identified during the primary and
assess whether there are other injuries to the patient during the secondary surveys requires a team approach and
accident radiologic studies.

CRITICAL CARE NURSING ❖ Diagnosis

• Expose/Environmental control Provide privacy
and assess if there are other injuries from the accident.
#1 is expose, so you provide privacy by putting a
blanket. Remove clothing to check injuries and prevent
heat loss by using a warm blanket or warm IV fluids.
• Initial vital signs and interventions. If there are
changes in temperature, RR, or BP that you have
observed, the interventions should be done or refer to
the doctor if the vital signs are decreasing.
• Oxygen saturation by pulse oximetry.
• Indwelling Urinary Catheter. If the patient cannot
urinate, insert a urinary catheter, but there is an
exception. DO NOT insert catheter if there is blood
on the meatus or the scrotum because it can
indicate a pelvic fracture.
• Gastric tube is inserted if there is evidence of facial
fracture.
• Laboratory studies are done especially electrolytes,
CBC and pregnancy test.
• Facilitate family presence, if there are procedures
done, you can allow a family member to be present to
witness.
• Provide comfort.
• If the patient is in pain, we use the PQRST pain
assessment.
o P – Provoke (are there any factors cause the
pain to increase or decrease?)
o Q – Quality (throbbing, gnawing, or pricking
pain, have the patient describe)
o R – Region (have them identify which part has
pain)
o S – Severity (using a scale of 1-10)
o T – Timing
HISTORY TAKING
• Part of secondary assessment.
• MIVT
M – Mechanism for injury to anticipate probable injuries.
(external or internal damage to understand the severity of
the injuries, time lapsed which is before patient receives
medical attention)
I – Injuries sustained or suspected, list those identified.
V – Initial VS of patient. For baseline data.
T – Treatment, what type of treatment was received before ER.
Treatment – what treatment did the patient receive before
arrival to hospital? What was his response to the intervention?
❖ For conscious patient, ask what happened?
• How did the accident occur?
• Why did it happen?
• Did he blacked out or fall?
❖ Obtain past medical history related to injury
• Provide a framework on which to build a plan of
appropriate client care and against which to measure
outcomes
❖ Outcome management, evaluation, and client
disposition
• Collaboration among health care providers
• Interventions are assigned priority according to severity
of client’s condition
• If no improvement with initial interventions, plan of care
reexamined and additional interventions maybe
required.
❖ Disposition
• Admitted to hospital
• Transfer to another hospital
• Release to home given with oral and written instructions
about follow-up care.
❖ Nursing Documentation
• Record of all assessment findings
• Diagnostic test done
• Interventions and management to the client
• Response to treatment
• Achieved outcomes
• Client education
• Complete but concise providing on-going
• Record of client’s condition and presence
TECHNICAL SKILLS
• Administration of medication via oral, subcutaneous,
intramuscular and intravenous
• Safe administration of immunization.
• Appropriate nursing interventions to adverse effects
from medications administered.
• Demonstrate basic therapeutic intervention
✓ Basic first aid skills
✓ O2 administration and ventilation technique
✓ Urinary catheter insertion
✓ NGT insertion
✓ Initial wound care
• Assess the need of decontamination procedure.
• Demonstrate knowledge and skills related to personal
protection and safety, including the use of PPE for
✓ Level A
✓ Level B
✓ Level C
✓Respiratory Protection
• Implement fluid/nutritional therapy, taking into account
the nature of injuries, agents expose to, and monitoring
hydration and fluid balance.
• Implement fluid/nutritional therapy, taking into account
the nature of injuries, agents expose to, and monitoring
hydration and fluid balance.
• Assess and prepare the injured for transport including
provision for care and monitoring during transport. If the
patient was given emergency drugs already, he/she is ready
for transport to the ward and the nurse will call the ward

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RTRMF – BSN LEVEL 4 LECTURER: Mrs. Evelyn U. Rances
NCM 118 BATCH TOPAZ

and ask if there is available bed for that patient and if the ✓ Condition and recreation
ward if full there is a place for that in the ER called the ✓ Immunization
waiting area. ✓ Environmental sanitation
• Demonstrate the ability to maintain client’s safety
during transport through splinting, immobilization, B. Secondary Prevention
monitoring and therapeutic interventions. If the patient • Emphasizes early detection of disease, prompt
has unstable vital signs, he/she is not ready for transport intervention, and health maintenance for individuals
because whatever happens during transport it is still a experiencing health problems, prevention of
death from the ER because you have not yet endorsed it to complications and disabilities.
the ward. ✓ Regular medical and dental checkup
• Demonstrate the use of emergency communication ✓ Adequate rest, food, and fluid intake
equipment and information management techniques in ✓ Good fecal and urinary elimination
a mass casualty incident response. ✓ Exercise
✓ Taking of maintenance drugs
COMMUNICATION ✓ Screening procedures (laboratory and radiologic
• Health care providers can communicate with each other, test)
with leadership, and with collaborating partners such as:
a) Policemen C. Tertiary Prevention
b) Firemen • To rehabilitate individuals and restore them to an
c) Security optimum level of functioning within the constraints of
d) Local hospitals disability. To prevent further complications.
• Radios will provide the bulk of communication ✓ Referral to a support group
• Regular telephones and walkie-talkies are helpful if ✓ Preventing complication
available. ✓ Referring client to a rehabilitation center to receive
• Cellular telephones maybe considered but limited by training that will maximize use of remaining
local infrastructure or geographical location of event abilities
CORE KNOWLEDGE AREAS HEALTHCARE SYSTEM AND POLICY
A. Health Promotion • Provides direction and standard with regards to health
• The process of enabling people to increase control over care delivery, reimbursement, evaluation, and
and to improve their health. education of health care professionals.
• Behaviors motivated by the desire to increase wellbeing • Changes in disaster health care policy will target new
and actualize human health potential. emphasis on the nation’s:
• Activities includes: ✓ Public health infrastructure
✓ Eating healthy and nutritious ✓ Information technology
✓ balanced diet ✓ Communication system
✓ Weight control ✓ Immunization
✓ Stress reduction ✓ Antibiotic therapy guidelines
✓ Stop smoking and drinking liquor ✓ Education preparation
✓ Rest and sleep for 8-10 hours ✓ Giving of disaster relief
✓ Decrease air pollution
✓ Exercise and fitness These healthcare system and policy is revised by the government
✓ Enhance relationship with family, every year with regard to the areas mentioned. Information
✓ Relatives, friends, and co-workers dissemination is done to inform the public regarding changes
that take place in the healthcare system and policies.
B. Risk Reduction
• To lessen threats, hazards, danger, adverse effects, PROFESSIONAL ROLE DEVELOPMENT
As an emergency room nurse, especially in times of disaster, you
damage, or loss of function to a population.
can assume several roles.

C. Disease Prevention • Researcher

• Actions or effects that helps avert eh onset or • Investigator/epidemiologist
deterioration of disease, disability, or injury. Examples • First responder
are immunization, lessen the effects of a disease, check-ups • Direct care provider or generalist nurse
yearly. • Advance practical nurse
• Coordinator of acre in hospital/nurse manager
TYPES OF PREVENTION
A. Primary Prevention • On site coordinator of care/incident commander
• Preventing the occurrence of death, injury, or illness in a • Information provider or educator
disaster. • Mental health counselor
• Activities include: • Member of planning response team
✓ Health education • Manager and coordinator of shelter
✓ Risk assessment for specific disease • Member of decontamination team
✓ Family planning • Triage officer
✓ Marriage counseling • On site director of care management
✓ Provision of adequate housing, work

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RTRMF – BSN LEVEL 4
NCM 118
These roles require qualifications or training. Do not assume
roles that you are not qualified in or trained for because you may
cause panic or chaos.
LEGAL ISSUES IN EMERGENCY NURSING
I. FEDERAL LEGISLATION MANDATES
• Any client who presents to an emergency department
seeking treatment must be rendered aid regardless of
financial ability to pay for services. In emergencies, the
patient should be brought to the nearest hospital regardless
if the patient could pay or not.
• The only time you transfer the patient to other hospital (as
requested by the family or the pt) is only done if the patient
is already in stable condition.
COBRA (Consolidated Omnibus Budget Reconciliation
Act)
◼ Requiring emergency personnel to stabilize the
condition of any client medically unstable before
transfer to another health care facility
◼ Emergency room personnel is tasked to monitor and
stabilize the pt’s condition
OBRA (Omnibus Budget Reconciliation Act 1990)
• This stabilization must occur regardless of the
client’s financial ability to pay for services
If pt is not stable OBRA is applied, where in the patient should
not pay any extra charges bisan extended iya stay ha emergency
room. (Stabilize the pt muna). Same la it ira purpose han COBRA
stabilize muna an patientbefore soliciting payment or referring
to another hospital.
EMTALA (Emergency Medical Treatment and Active
Labor Act)
• Medical screening examination be performed on all
emergency clients before solicitation of information
about ability to pay. If the patient is still not stable and
his stay in the emergency room/hospital is extended
the hospital is mandated to provide medical
screening, diagnostics, laboratory examinations etc…
even if the patient is does not have the capacity to pay
or if the patient will be transferring pa once stable
NO DEPOSIT LAW
• Giving of emergency care to clients who is incapable
of paying or giving deposit for services rendered.
When the pt is stabilized and is ready to be transferred, the
patient is not allowed to pay any deposit for the care/ materials
used in the emergency room. The hospital should not ask for any
deposit kase it nanabo labi na kun it client na accidente so
syempre an pinaka hirani na hospital kay private hospital kay it
EVRMC hirayu. So kinahanglan na niya emergency care so
dadaon ha private hospital. What happens ha mga private
hospital diri nakarawat kun it pasyente diri anay na deposit. So
ini na no deposit law amo ini it na dictate ha mga private
hospitals na you should provide first emergency care to the
clients whether they are capable or not capable of giving deposit
for services rendered. So dapat emergency care anay na deposit
needed”.
LECTURER: Mrs. Evelyn U. Rances
BATCH TOPAZ
II. CONSENT TO CARE / TREATMENT
Should you decide to stay in the hospital? It is now your decision.
This is the time where the hospital will now charge you since you
have given your consent to care/treatment in the hospital.
a) Client unable to give consent to treatment thus
emergency care rendered under the "IMPLIED
EMERGENCY DOCTRINE"
- assumes that client would consent to
treatment to prevent death or disability if were
so able
- In concious pt, the patient is the oone who signs
the consent. But, in cases where the patient is
unconscious or comatose without any family
member that was rushed to the hospital due to
an emergency situation the implied emergency
doctrine would prevail. Who signs on behalf of
the client kun diri makaka sign? It is the attending
physician who signs on behalf of the patient kun
kailangan hin emergency treatment.
b.) Minor or younger children must have the consent
of their parents or legal/lawful guardian
- “So, in case a minor or young child is brought to
the hospital in an emergency the parents or
legal/lawful guardian will be the one to sign. Kun
care giver la hia bisan diri member of the family
because they were the one caring for the child
tapos an parents are not available then the care
giver will be the one to sign on behalf of the child”.
For medical care to be rendered with the exceptions:
1. Emancipated minors. “an mga minor kun adat her ana
ukoy ha era parents kinahanglan hin consent hit era parents kay
minor pa hera. Pero kun nag lugaring na ito na minor, they are
living on their own so emancipated na ito na minor they can sign
for themselves”
2. Minors seeking treatment for communicable diseases,
including sexually transmitted diseases, injuries from abuse,
and alcohol or drug rehabilitation. “So, for example nagka
mayada nah in experience hin premarital sex with partner and
may STD and natapnan hia. Puydi hia mag seek hin treatment
for communicable disease or injury from abuse bisan minor
hiya”
3. Minor aged females requesting treatment for
pregnancy or pregnancy related concerns.
4. Adult caregiver with whom the child resides is allowed
to give treatment authorization.
III. RESTRAINTS
• The need of restraints usually arises because the client
is becoming agitated or potentially violent.
• Hard leather or chemical restraint are used on client in
danger of injuring self or others. “So, puydi kita mag
injection hin drug para it patient mangaturog that is a form
of chemical restraints. Hard leather you can use in tying the
extremities of the patient”.
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RTRMF – BSN LEVEL 4
NCM 118
Conditions of applying restraint:
1. Doctor's order to apply restraint.
2. Client's behavior mandating the use of restraint
must be documented. “In your charting ibubutang
mo agitated an px, violent to themselves and to others,
nanlalabay, nan mamalbag”
3. Has departmental or hospital guidelines or written
policy. “So, see to it na mayda kamo written policies
on provision of restraints kay bangin waray kamo
guidelines tapos na silip hito han mga family members
so pwede kamo mademand”
IV. Mandatory Reporting
Incidents and conditions need to be reported to local
authorities most especially to the DOH:
• Suspected child abuse “ito na Womens and Child protection
desk an hospital mayda hito. So kun mayda kita incidence na
umabot an bata damo an samad because of child abuse gin
paso han sigarilyo, may mga lacerations, abrasions, and
hematoma that is the sign of child abuse pwede ito ireport ha
womens and child protection desk”
• Sexual abuse “na rape, gin molest han member of the family”
• Domestic abuse “ito na mga maid na gin kastigo han era amo
diri gin papa kaon, may mga paso han sigarilyo, hematoma,
lacerated wounds”
• Elder abuse
• Assaults “gin titinarhog “mag sumat ka ngani papatayon ko it
imo mga bugto”
• Motor vehicle crashes
• Communicable diseases
• Animal bites “dog, cat, rat and even human bites”
V. Violence against emergency department personnel
• Administrative changes have been made: "To enhance
both public and health care workers safety"
Measures includes the installation of:
1. Metal detectors
2. Bullet proof glass
3. Lock down doors at the public entrance
4. Increasing visibility of security guards
5. Using patrol guard dogs
6. Panic buttons
ETHICAL ISSUES
• Deal with end-of-life concerns
• Initial resuscitation.
• Stabilization of clients in critical condition
A. Unexpected Death:
1. Allowing family members or SO To be present
during client resuscitation. So, they would see
something has been done to the client but once the SO
or family members would create chaos during
resuscitation then they are sent out.
2. The attending doctor informs family when
death occurs. Explains what happened to the
client, what has been done, what drugs have been
injected, and what was the condition that caused
death.
3. Refer to the deceased client by name. “So, when
a patient dies, see to it that all the gadgets will be
LECTURER: Mrs. Evelyn U. Rances
BATCH TOPAZ
removed and provide post mortem care. “We tag the
patient with his/her full name as with the diagnosis for
post-mortem care”
4. Provide the family with explanation of the
course of events related to the death.
5. Offer an opportunity to view the body.
6. Help family to focus on decision requiring
immediate attention on:
• Valuables. Make sure that it is a family member,
because sometimes SO of other patients are curious
when someone is being resuscitated and would stay
near the bedside, so they are sometimes being
mistaken as the family member of the one who died
and are given the valuables and these might be lost
and the nurse will be liable.
• Arranging post-mortem examination if desired. You
could offer to have the patient autopsied if the family
desires to know the cause of death, however if they do
not want then we should not force them.
• Identifying possible organ or tissue donation. Let
the family members decide if they want to donate the
organs or not, do not be the one to open up about this
topic because if the family really wants to donate the
organ or tissue, they will be the one to inform you.
• Selecting funeral homes. Do not advertise funeral
homes. Inform the family to call their desired funeral
home.
7. Inform family members when they can leave the
hospital. Make sure that there is a temporary death
certificate, this is the responsibility of the nurse which is
written by the doctor. There is an encoded death certificate
but it will be released after 3 days. Make sure to obtain this
or else the patient will not be embalmed. If the patient died
in the ER, the one who will issue the death certificate is the
doctor who assessed the patient. If the patient is about to
enter ER just before the door, the resident doctor will not
issue death certificate, it is the City Health Office kay waray
pa makasulod han hospital.
8. Provide community referral if needed.
9. Advance directives: emergency care personnel are
obligated to abide the patients written advance
directive decisions. If an patient waray advance directive,
sometimes the relatives can make directives especially if
they see the patient about to die and suffering, they would
opt to let the patient die peacefully but make sure to obtain
DNR with signature, if there is none then continue do CPR.
CHILD ABANDONMENT
• The nursery nurse after 24 hours of abandonment
should contact DSWD
• The mother does not claim criminal liability upon
abandoning the child
EMERGENCY NURSING
• Is an assessment, diagnosis and treatment of
perceived, actual, potential, sudden or urgent
physical or psychomotor problems that are primarily
episodic or acute.
• In emergency room setting, they only need minimal
care The disposition would depend on the doctor,
whether to admit, to transfer, or to send the patient
home with prescription drugs.
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RTRMF – BSN LEVEL 4 LECTURER: Mrs. Evelyn U. Rances
NCM 118 BATCH TOPAZ

• It also requires life support measures, education of 5 LEVELS OF ACUITY

client and significant members of the family,
appropriate referral and knowledge of legal Conditions requiring
implications immediate nursing and
physician assessment. Any
The standard of care guidelines. You do an emergency delay is potentially life
assessment and do emergency interventions. threatening. Such as airway

The components of care would include: Level 1: Resuscitation compromise, cardiac arrest,
- Once the patient enters the emergency room, they pass severe shock, cervical spine
through the triage area injury, multi system trauma,
altered level of consciousness
A triage is prioritizing, separating or selecting. You determine or eclampsia
the severity of a client’s problem or condition, level of acuity
Conditions requiring nursing
or priority. Sort out people based on their emergency needs
and doctor’s assessment
and treat them. Ha triage mismo, ikawt magcacategorize kun
within 15 minutes of arrival.
Level 1 tun hiya, Level 2, Level 3, Level 4, Level 5? So ada iton ha
Such as head injuries, severe
ira computer. Pag adto ka na assign ha triage, pagpindot mot
trauma, severe allergic
computer adto ito it different levels tas may mga corresponding
signs and symptoms ito hira. Level 2: Emergent reaction, lethargic or agitation,
stroke, GI bleeding with
3 TYPES OF TRIAGING unstable vital signs,
medication overdose and
1. START Triage
unconscious.
• START means simple triage and rapid treatment.
Conditions requiring nursing
This was developed by the Newport Beach
California Fire and Marine Department at Hoag and doctor’s assessment
Hospital Emergency Medical Service. This is based within 30 minutes of arrival.
on the patient’s ability to respond verbally and Such as alert head injury,
ambulate, their respiration, perfusion and mental Level 3: Urgent vomiting, mild to moderate
status asthma, moderate trauma,
abuse or neglect, GI bleeding
2. Military Triage
with stable vital signs, history
Uses military mission’s objective that guides the
of seizure, alert on arrival
triage and transport decision. This Includes:
Conditions requiring
Priority 1: Immediate Care - So ano na mga problema iton it assessment within 1 hour of
aada? When patient is in shock, there is airway problem, there is arrival. Such as minor allergic
chest injury, amputation or open fracture Level 4: Less Urgent reaction, foreign body,
Priority 2: Minimal Care - Little or no treatment is needed vomiting and diarrhea in 2
Priority 3: Delayed Care - Treatment may be postponed years old without evidence of
without loss of life, noncritical, simple fracture, non-bleeding dehydration and chronic
laceration backpain
Priority 4: Expectant Care - No treatment until immediate Conditions requiring
and related priority patients are cared for. Required to save assessment within 2 hours of
their time, effort and supplies. It 4 last priority na ito hira na Level 5: Non-Urgent arrival. Such as minor trauma,
pasyente didto ha emergency room. Uunahon anay an mga sore throat, chronic
critical, pag waray na an mga critical hira na sunod it macacare abdominal pain

OTHER CATEGORIES OF TRIAGING ----- END -----

1. Emergent Category
Client must be treated immediately otherwise life is
in danger

2. Urgent Category
Client requires treatment but life is not threatened
if care is given within 1 to 2 hours

3. Non-Urgent Category
Client requires evaluation and possible treatment
but time is not a critical factor. Last priority iron hira.
This is the type of triage system that is used by
emergency room at EVMC.

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