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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
III. Circulation
Causes: - Any heart problem is a circulatory problem
3 most common causes: 3 classifications of Shock
A. Hypovolemic shock -
Other causes: B. Cardiogenic Shock –
-aspiration of foreign objects C. Distributive Shock -
-trauma
-inhalation of chemical burns A. Hypovolemic shock
A. aspiration of foreign objects  Assessment:
- 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  Mgt
nostrils The goals of the emergency management:
- Increased anxiety, restlessness, confusion 1.
- Cyanosis and dec. LOC (late sign) 2.
3.
 The goals of the emergency management:
 Management: OPEN AIRWAY 1. Control the Bleeding - stopping the bleeding is
1. Partial obstruction – pt can breath and essential to the care and survival of patients in an
cough spontaneously emergency or disaster situation
mgt: encourage pt to 2. Maintain adequate circulating blood volume by
2. Complete Airway Obstruction – establish IV line for fluid replacement
mgt: Reposition the pt’s head
a. 3. Prevent Shock
b. – pt is maintained in the shock position
- Assess pt for breathing by watching for
chest movement and listening and feeling  Quality and Safe Nursing Alert
for air movement The infusion rate is determined by
ESTABLISHING AN AIRWAY ______________________ the and the clinical
1. Oropharyngeal airway evidence of ___________. Any blood replacement
- circular tubelike plastic device therapy should be given via __________ when
- inserted over the back of the tongue into possible, because administration of large amounts
the lower posterior pharynx of blood that has been refrigerated has a core
- for pt: cooling effect that may lead to ___________ and
- purpose: prevents the tongue from falling _______________.
back causing obstruction in airway; also allows
suctioning of secretions IV. Disability
2. Nasopharyngeal airway - Determine neurologic disability
- provides the same airway access but
inserted in the nares
- a nasopharyngeal airway should be tried if V. Exposure
a pt does not tolerate OP - Undress the pt ___________ and
 Quality & Safety Nursing Alert _____________ so that any wounds or
In case of potential facial trauma or basal areas of injury are identified.
skull fracture, the nasopharyngeal airway should - To assess wounds and injuries immediately
not be used because it could enter the brain cavity
instead of the pharynx. ***EXERCISE
3. Endotracheal Intubation 1. It is the purpose of Primary survey
• Purpose 2. Leads to permanent brain damage and
• Indications: death within 3-5 mins
- 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 unconscious
- provide adequate ventilation 6. Used to establish and maintain the airway in
- Pt’s who have experienced trauma must have patients with respiratory insufficiency or
the cervical spine protected and chest injuries hypoxia
assessed first, immediately after securing airway 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 –  Antivenin – antitoxin manufactured from
external) increase blood flow to the the snake venom and used to treat
acidotic, anaerobic extremities snakebites
b. Forced-air warming blankets (active – - Assessment of progressive s & sx is
external) essential before the administration of
- WOF: extremity burn, pt may not have antivenin
effective sensation to feel burn - Most effective given within ______ post bite
- Serum sickness is a type of hypersensitivity
III. Nonfatal Drowning response: before administering antivenin
- Survival for at least 24 hrs after submersion and every 15mins thereafter, the
that caused a respiratory arrest circumference of the affected part is
- The majority of drowning events occur in measured
________, ________ and ________ - Can be given ___ or ____
- Depending on the severity of the snakebite,
 Prevention antivenin is diluted in 500 or 1000 mL NSS
1. Avoiding rip currents offshore - Infusion is started slow then the rate is
2. Surrounding the pool with fencing increased after _______ if no reaction
3. Self-latching/closing gate - The total dose should be infused during the
4. Providing swimming lessons first 4-6 hrs after the bite.
5. Personal floatation device - The initial dose is repeated until sx decrease
*_______________________ is still the best - There is NO limit to the number of antivenin
prevention measure vials that can be given.
 Major Complications
- After resuscitation: ***EXERCISE
- Pulmonary injury depend on the type of 1. Heat induced illness due to exposure to envi
fluid aspirated temp >38.8˚c
• Freshwater – 2. Most serious heat induced illness
• Salt-water – 3. Optimal method for cooling
 Management 4. Hypothermia: core body temperature is
1. The factor with the greatest influence on ____ or less
survival: 5. Forced-air warming blankets is what type of
2. Treatment goal: rewarming method
3. Rectal probe 6. The best prevention measure of drowning
4. Indwelling FBC 7. Injection of a poisonous material by sting,
5. ECG monitoring spine, bite or other means
6. NGT for decompression – 8. Most common site of snakebite
IV. SNAKEBITES 9. Antivenin Most effective given within
- venomous snakebites are medical 10. Antivenin can be given via
emergencies DISASTER NURSING
- The most common site is the:
• Envenomation –  TRIAGE CATEGORIES
 Classic clinical signs of envenomation: In a disaster, when HCP are faced with a large
 Management number of casualties, the fundamental principle
 Initial first aid at the site: guiding resource allocation is to do good for the
- have the person lie down greatest number of people
- remove constrictive items( ring) The North Atlantic Treaty Organization
- provide warmth (NATO) Triage system
- cleansing the wound - Most widely used triage category
- covering the wound with a light sterile - Consist of four colors: red, yellow, green
dressing and blue, each color signifies a different
- Immobilize below the level of the heart level of priority

 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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