Medical-Surgical Nursing: An

Integrated Approach, 2E
Chapter 37
NURSING CARE OF
THE CLIENT:
RESPONDING TO
EMERGENCIES
Emergency: Defined as:
 A medical or surgical condition requiring
immediate or timely intervention to
prevent permanent disability or death.
 In the U.S., trauma is the number one
killer of those under the age of 37 and the
fourth leading cause of death overall.
Emergency Nursing
 The care of clients who require
emergency intervention.
 The emergency nurse must be capable of
rapid assessment and history taking and
immediate intervention formulation and
implementation using the nursing
process.
 Clinical knowledge, communication, client
teaching, and empathy skills are
essential.
Approaches to Emergency Care
 There are three general approaches to
emergency care:
 Hospital triage.

 Disaster triage.

 Emergency medical services.

Hospital Triage
 Triage refers to classification of clients to
determine priority of need and proper
place of treatment.
 Each hospital with an emergency
department (ED) has an established
triage system in place.
Golden Rules of Emergency
Care
1. Establish the safety of the scene.
2. Remove the client from danger.
3. Establish airway, breathing, and
circulation.
4. Manage shock.
5. Attend to eye injuries.
6. Treat skin injuries.
7. Call for help.
Triage Classifications
 Emergent (clients who require immediate
care in order to sustain life or limb).
 Urgent (clients who require care within 1
to 2 hours to prevent worsening of their
condition).
 Non-urgent (clients whose care can be
delayed without the risk of permanent
consequences).
Disaster Triage
CATEGORY CLIENT NEEDS EXAMPLES
Immediate Simple injuries Chest wounds
requiring Crush injuries
immediate care Burns
Delayed Multiple injuries Open fractures of
requiring extensive the long bones
care
Minimal Minor injuries (the Sprains, minor cuts
walking wounded) Contusions

Expectant Severe injuries Massive head

likely to cause trauma, spinal cord
death injuries
Emergency Medical Services
 Prior to admission to the ED, the client may
have been cared for by an emergency medical
technician (EMT) or paramedic.
 An EMT is a health care professional trained to
provide basic lifesaving measures prior to
arrival at the hospital.
 A paramedic is a more specialized health care
professional trained to provide advanced life
support to the client requiring emergency
interventions.
Shock: Defined as:
 A condition of profound hemodynamic and
metabolic disturbance characterized by
inadequate tissue perfusion and
inadequate circulation to the vital organs.
Types of Shock
TYPE CAUSES

Hypovolemic Hemorrhage; Burns

Cardiogenic Myorcardial Infarction
Toxic Overwhelming
Infection
Anaphylactic Medications, insect
bites or stings, food
Neurogenic Spinal cord injury
Cardiopulmonary Emergencies
 Those that jeopardize the function of the
hearts and lungs.
 Include drowning, foreign body
obstruction of the airway, chest trauma,
and chest pain.
Neurological/Neurosurgical
Emergencies
 Head injuries are the most common type
of neurological trauma.
 Spinal cord trauma can also occur as a
result of injuries sustained in a head
injury.
 Head injuries most common in motor
vehicle collisions.
 Cerebrovascular accidents, or stroke, also
require emergency care.
Abdominal Emergencies
 Abdominal emergencies can be diverse in
nature.
 Include trauma as well as illnesses that
cause abdominal pain (gastroenteritis,
gastrointestinal bleeding, etc.).
Genitourinary Emergencies
 Include rape.
 Straddle injuries (those that occur when a
client falls while straddling an object, such
as a fence or metal bar, thereby injuring
the perineum).
Ocular Emergencies
 Most eye emergencies are urgent to
emergent in nature.
 Foreign bodies can cause damage to
vision very rapidly and thus require
immediate attention.
Musculoskeletal Emergencies
 Can vary from simple strains to major
trauma.
 Includes sprains, dislocations, fractures.
Soft Tissue Emergencies
 Most soft-tissue injuries are very
common, including minor abrasions,
lacerations, puncture wounds, contusions,
bites of all varieties, and burn injuries.
 Although most do not require emergency
care, some are more severe than others
and some are potentially fatal.
Poisoning and Overdoses
 Can be accidental or intentional.
 Ingested poisons are most common.
 Important to obtain a clear history of the
route of entry: inhalation, ingestion,
topical, or injection.
Environmental/Temperature
Emergencies
 Exposures to extremes of heat and cold
can be potentially life threatening.
 Severe cold, or hypothermia, frostbite,
extreme heat are examples.
Degrees of Frostbite Severity
DEGREE SYMPTOMS TREATMENT

Mild Skin cold to touch, Use blankets,

pale, tingling, numb warm clothing to
warm cold flesh

Moderate Affects deeper Use gloves,

body tissue, skin blankets, warm
waxy, puffy, itchy, clothing to warm
burning with pain cold flesh
Severe Blistering, soft Initiate emergency
tissue damage, rewarming using
flesh hard, lifeless, warm water baths;
no pain observe for edema
Comparison of Heat Injuries
TYPE SYMPTOMS TREATMENT

Heat Cramps Muscle cramps in Move client to cool,

arms, leg, and shady area. Slowly
abdomen administer copious
water. Reevaluate.
Heat Exhaustion Diaphoresis, pale, Move client to cool,
moist, cool skin, shady area. Pour
headache, water over client.
dizziness, etc. Elevate legs.
Heat Stroke Red, flushed, hot Emergency
(medical dry skin; no treatment.
emergency) diaphoresis.
Multiple System Trauma
 Injury sustained in more than one body
system.
 During the initial care of the emergency
client, the mechanism of injury is
determined.
 Blunt injuries and penetrating trauma are
most likely to result in multiple-system
involvement.
Legal Issues
 Nurses must be aware of the legal issues
related to emergency care, such as Good
Samaritan Laws and mandated reporting.
Death in the Emergency
Department
 Death can occur in the ED at any time
due to trauma, sudden illness, or even
extended illness.
 In the event of sudden death, the family is
usually in a state of shock and will need
further assistance to cope with the death
of their loved one.
 Special support groups are available for
this assistance and should be contacted
for the family.