Emergency nursing involves providing care for patients with undiagnosed or life-threatening medical issues. Nurses in the emergency department are specially trained to quickly assess patients and identify health problems during crisis situations. The primary goals of emergency care are to establish a patient's airway, breathing, circulation, and neurological status (known as the ABCD approach) and begin any immediately necessary interventions. Triage is also used to sort patients based on the severity of their condition in order to prioritize care for those in most urgent need of medical attention.

1. Dr/Higazi Mohammed Ahmed Abdallah Awad

2. Emergency nursing
Defined as “the care of individuals
across the lifespan with perceived or
actual physical or emotional alterations
of health that are undiagnosed or
require further interventions.

3. Emergency care
can be defined as the episodic and
crisis-oriented care provided to
patients with serious or potentially
life-threatening injuries or illnesses.

4. Scope and Practice of Emergency
Nursing
The emergency nurse has had specialized:-
 Education
 training
 experience
 expertise in assessing and identifying patients'
health care problems in crisis situations

6. General protocol elements
 area ( setting )
 Design
 Staff
 Principle

8. Principles of Emergency Care
Triage

9. The word triage comes from the French
word trier, meaning “to sort.”
triage is used to sort patients into groups
based on the severity of their health
problems and the immediacy with which
these problems must be treated.

10. Classification
 Emergent patients have the highest priority—their conditions
are life-threatening and they must be seen immediately.
 Urgent patients have serious health problems but not
immediately life-threatening ones; they must be seen within 1
hour.
 Nonurgent patients have episodic illnesses that can be
addressed within 24 hours without increased morbidity
 fast-track.” These patients require simple first aid or basic
primary care and may be treated in the ED or safely referred to
a clinic or physician's office.

11. Triage
Scale:
CATEGORY DESCRIPTION time
1 Resuscitation Immediately
2 Emergency 10 minute
3 Urgent 30 minute
4 Semi-urgent 60 minute
5 Non-Urgent 2 hours

16. Triage Categories
 Triage Level I (Resuscitation):
 Conditions requiring immediate nursing and physician assessment.
Any delay in treatment is potentially life-threatening.
 Includes conditions such as:
 Airway compromise.
 Cardiac arrest.
 Severe shock.
 Cervical spine injury.
 Multisystem trauma.
 Altered level of consciousness (LOC) (unconsciousness).

17. Triage Level II – (Emergent)
 Conditions requiring nursing assessment and physician assessment within 10
to 15 minutes of arrival.
 Conditions include:
 Head injuries.
 Severe trauma.
 Lethargy or agitation.
 Conscious overdose.
 Severe allergic reaction.
 Chemical exposure to the eyes

18. Triage Level III (Urgent)
 Conditions requiring nursing and physician assessment within 30 minutes of
arrival.
 Conditions include:
 Alert head injury with vomiting.
 Mild to moderate asthma.
 Moderate trauma.
 Abuse or neglect.
 GI bleed with stable vital signs.
 History of seizure, alert on arrival.

19. Triage Level V (Non urgent)
 Conditions requiring nursing and physician assessment within two hours.
 Conditions include:
 Minor trauma, not acute.
 Sore throat.
 Minor symptoms.
 Chronic abdominal pain.

20. Assess and Intervene

21.  Prevention of cross-
infection
Remember
 General appearance of
the patient
 Communication with the
patient
 Patient-monitoring
devices
 Senior help

22. ABCD (airway, breathing, circulation,
disability) method:
 Establish a patent airway.
 Provide adequate ventilation, employing resuscitation measures
when necessary. (Trauma patients must have the cervical spine
protected and chest injuries assessed first.)
 Evaluate and restore cardiac output by controlling hemorrhage,
preventing and treating shock, and maintaining or restoring
effective circulation. This includes the prevention and
management of hypothermia.
 Determine neurologic disability by assessing neurologic function
using the Glasgow Coma Scale

23. What these picture refer to
look Listen
Feel

24. Airway mean
To ensure patency , provide adequate
ventilation , and maintain appropriate
oxygenation
appropriate administration of high flow
oxygen , with properly fitted mask is
beneficial.

25. Primary Assessment
A :Airway:
 Does the patient have an open airway?
 Is the patient able to speak?
 Check for airway obstructions such as loose
teeth, foreign objects, bleeding, vomitus or
other secretions. Immediately treat
anything that compromises the airway

26. Look, listen and feel for the signs of airway obstruction.
Partial airway obstruction will result in noisy breathing:
gurgling
wheeze
stridor
snoring

27. If airway is compromised, or is at risk,
take immediate action
 apply head tilt/chin lift to open the airway;
 suction the airway if secretions, blood or gastric
contents are present;
 place the patient in the lateral position if breathing, but
has altered conscious level;
 if the patient is unconscious, insert an oropharyngeal
airway or (a nasopharyngeal airway may be helpful in a
patient who is semi-conscious);

28. head tilt/chin lift

29. Jaw thrust

30. Airway tube

32. oropharyngeal

33. Nasopharyngeal

34. Nasopharyngeal

35. If airway is compromised, or is at risk,
take immediate action
 advanced airway intervention, :-
tracheal intubation
tracheostomy
may be required in some situations;
 administer high-concentration oxygen.

36. Primary Assessment
B :Breathing:
 Is the patient breathing?
 Assess for equal rise and fall of the chest (check
for bilateral breath sounds), respiratory rate and
pattern, skin color, use of accessory muscles,
integrity of the chest wall, and position of the
trachea.
 All major trauma patients require supplemental
oxygen via a nonrebreather mask.

37. Count the respiratory rate
Evaluate depth of breathing Evaluate respiratory pattern
Note the oxygen saturation (SpO2)
reading
Listen to the breathing
Evaluate chest movement
Palpate the chest wall
Check the position of the trachea
Perform chest percussion:

38. Evaluate the efficacy, work of
breathing and adequacy of ventilation
 Efficacy of breathing: air entry, chest
movement, pulse oximetry, arterial blood gas
analysis and capnography.
 Work of breathing: respiratory rate and use of
accessory muscles, for example neck and
abdominal muscles.
 Adequacy of ventilation: heart rate, skin
colour and mental status.

39. Primary Assessment
C:Circulation:
 Is circulation in immediate jeopardy?
 Can you palpate a central pulse? What is
the quality (strong, weak, slow, rapid)?
 Is the skin warm and dry?
 Is the skin color normal? Obtain a blood
pressure (in both arms if chest trauma is
suspected).

40. Primary Assessment
D:Disability:
 Assess level of consciousness and pupils (a more complete
neurologic survey will be completed in the secondary survey).
 Assess level of consciousness using the AVPU scale:
A=Is the patient alert?
V=Does the patient respond to voice?
P=Does the patient respond to painful stimulus?
U=The patient is unresponsive even to painful stimulus

41. Secondary Assessment
 The secondary assessment is a brief
 systematic assessment designed to identify all injuries.
 The steps include:-
 Expose/environmental control
 Full set of vital signs
Five interventions
Facilitate family presence
Give comfort measures

42. Secondary Assessment
 Expose/environmental control: It is necessary to remove
the patient's clothing in order to identify all injuries. You
must then prevent heat loss by using warm blankets,
overhead warmers, and warmed I.V. fluids.
 Full set of vital signs/five interventions/facilitate family
presence:
Obtain a full set of vital signs including blood pressure,
heart rate, respiratory rate, and temperature.
 As stated previously, obtain blood pressure in both arms
if chest trauma is suspected.

43. Secondary Assessment
 Five interventions:
Pulse oximetry to measure the oxygen saturation
Indwelling urinary catheter (do not insert if you note blood at the
meatus, blood in the scrotum, or if you suspect a pelvic fracture)
Gastric tube (if there is evidence of facial fractures, insert the tube
orally)
Laboratory studies frequently include type and crossmatching,
hemoglobin and hematocrit, urine drug screen, blood alcohol,
electrolytes, prothrombin time (PT) and partial thromboplastin
time, and pregnancy test if applicable

44. Secondary Assessment
Facilitate family presence: It is
important to assess the family's needs.
Give comfort measures: These include
 verbal reassurances
 pain management
 comfort measures to the family
during the resuscitation process.

45. After these priorities have been
addressed
 complete health history and head-to-toe assessment
 Diagnostic and laboratory testing
 Insertion or application of monitoring devices such as electrocardiogram
(ECG) electrodes, arterial lines, or urinary catheters
 Splinting of suspected fractures
 Cleansing, closure, and dressing of wounds
 Performance of other necessary interventions based on the patient's condition

46. Types of scale used in ER