2. 
A systematic approach to the assessment of
an emergency patient is essential. The
primary and secondary surveys provide the
emergency nurse with a methodical approach
to help identify and prioritize patient needs.

3. 

The initial, rapid, ABCD (airway,
breathing, and circulation, as well as
neurologic disability resulting from spinal
cord or head injuries) assessment of the
patient is meant to identify lifethreatening problems.
If conditions are identified that present an
immediate threat to life, appropriate
interventions are required before
proceeding to the secondary assessment.

4. Emergency Assessment and Intervention
 When a patient presents with a
potentially life-threatening condition,
proceed swiftly with the following:
 Remove the patient from potential source of
danger, such as live electric current, water, or fire.
 Determine whether patient is conscious.
 Assess airway, breathing, and circulation in
systematic manner.
continuation

5. Emergency Assessment and Intervention
 When a patient presents with a
potentially life-threatening condition,
proceed swiftly with the following:
 Assess pupillary reaction and level of
responsiveness to voice or touch as indicated.
 If the patient is unconscious or has sustained a
significant head injury, assume there is a spinal
cord injury and ensure proper handling.
 Undress the patient to assess for wounds and skin
lesions as indicated.
continuation

6. Emergency Assessment and Intervention
 When a patient presents with a potentially lifethreatening condition, proceed swiftly with the
following:
 Immediate intervention is needed for such
conditions as compromised airway, respiratory
arrest, compromised respirations, cardiac arrest,
and profuse bleeding. Provide emergency airway
management, cardiopulmonary resuscitation, and
measures to control hemorrhage as needed.
 Call for help as soon as possible.
 Assist with transport and further assessment and
care as indicated.

8. 
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.
continuation

9. 
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,
adventitious breath sounds, integrity of the chest
wall, and position of the trachea. All major
trauma patients require supplemental oxygen via
a nonrebreather mask.
continuation

10. 
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 ([BP]; in both arms if
chest trauma or dissecting aortic aneurysm is
suspected).
continuation

11. 
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.

12. 

The secondary assessment is a brief,
but thorough, systematic
assessment designed to identify all
injuries.
The steps include:
 Expose/environmental control,
 Full set of vital signs/
 Five interventions/
 Facilitate family presence, and

13. 
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 unless induced hypothermia is
indicated.

14. 



Obtain a full set of vital signs including BP, heart
rate, respiratory rate, and temperature.
As stated previously, obtain BP in both arms if
chest trauma or dissecting aortic aneurysm is
suspected.
Institute continuous cardiac monitoring.
Assess Glasgow Coma Scale (GCS) and pain
score.

15. 




Vascular access
Pulse oximetry to measure the oxygen saturation; consider
capnography to measure end-tidal carbon dioxide; noninvasive
ultrasonic cardiac output monitor ; and electrocardiogram (ECG)
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 rather than nasally)
Laboratory studies frequently include type and cross-matching,
complete blood count (CBC), urine drug screen, blood alcohol,
electrolytes, prothrombin time (PT) and partial thromboplastin
time (PTT), arterial blood gas (ABG), and pregnancy test if
applicablle

16. 
It is important to assess the family's needs. If
any member of the family wishes to be
present during the resuscitation, it is
imperative to assign a staff member to that
person to explain what is being done and
offer support.

17. 
These include verbal reassurances as well as
pain management as appropriate. Do not
forget to give comfort measures to the family
during the resuscitation process.

18. 
Obtain prehospital information from
emergency personnel, patient, family, or
bystanders using the mnemonic MIVT.
 M—Mechanism of injury
 I—Injuries sustained or suspected
 V—Vital signs
 T—Treatment

19.  It is helpful to understand the mechanism of injury to
anticipate probable injuries. It is particularly helpful in motor
vehicle accidents to know such information as external and
internal damage to the car and the period of time elapsed
before the patient received medical attention.

20. 
Ask pre-hospital personnel to list any injuries that they
have identified.

21. 
What were the prehospital vital signs?

22. 
What treatment did the patient receive before arriving
at the hospital and what was patient's response to those
interventions?

23. If the patient is conscious, it is essential to ask
him what happened. How did the accident
occur? Why did it happen? A fall, for example,
may not be a simple fall—perhaps the patient
blacked out and then fell. If the patient is
conscious and time permits, explore the chief
complaint through the PQRST mnemonic.
 P—Provokes, Palliates, Precipitates
 Q—Quality
 R—Region, Radiates
 S—Severity, associated Symptoms
 T—Timing (onset, duration)


24. 
Obtain past medical history from the patient
or a family member or friend, including age,
medical/surgical history, current medications,
use of any illicit drugs, allergies, last
menstrual period, last meal, and last tetanus
shot.

25. 
The head-to-toe assessment begins with
assessment of the patient's general
appearance, including body position or any
guarding or posturing. Work from the head
down, systematically assessing the patient
one body area at a time.

26. 
Head and face
 Inspect for any lacerations, abrasions, contusions,
avulsions, puncture wounds, impaled objects, ecchymosis,
or edema.
 Palpate for crepitus, crackling, or bony deformities.

27. 
Chest
 Inspect for breathing effectiveness, paradoxical chest wall
movement, disruptions in chest wall integrity.
 Auscultate for bilateral breath sounds and adventitious
breath sounds.
 Palpate for bony crepitus or deformities.

28. 
Abdomen/flanks
 Inspect for lacerations, abrasions, contusions, avulsions,
puncture wounds, impaled objects, ecchymosis, edema,
scars, eviscerations, or distention.
 Auscultate for the presence of bowel sounds.
 Palpate for rigidity, guarding, masses, or areas of
tenderness.

29. 
Pelvis/perineum
 Inspect for lacerations, abrasions, contusions, avulsions,
puncture wounds, impaled objects, ecchymosis, edema, or
scars. Look for blood at the urinary meatus. Look for
priapism (which could indicate spinal cord injury).
 Palpate for pelvic instability and anal sphincter tone.

30. 
Extremities
 Inspect skin color and temperature. Look for signs of injury
and bleeding. Does the patient have movement and
sensation of all extremities?
 Palpate peripheral pulses, any bony crepitus, or areas of
tenderness.

31. 
Posterior surfaces—utilizing help, logroll the
patient in order to:
 Inspect for possible injuries.
 Palpate the vertebral column and all areas for tenderness.

32. 
Any injuries that were identified during the
primary and secondary surveys require a
detailed assessment, which will typically
include a team approach and radiographic
studies.

33. 


Triage is a French verb meaning “to sort.”
Emergency triage is a subspecialty of
emergency nursing, which requires
specific, comprehensive educational
preparation.
Patients entering an emergency
department (ED) are greeted by a triage
nurse, who will perform a rapid evaluation
of the patient to determine a level of
acuity or priority of care. .

34. 
The triage nurse will assess:
 the patient's chief complaint;
 general appearance; ABCD;
 environment; limited history; and
 comorbidities.

35. 
Thus, the primary role of the triage nurse is
to make acuity and disposition decisions
and set priorities while maintaining an
awareness for potentially violent or
communicable disease situations.

Secondary triage decisions involve the
initiation of triage extended practices.

36. 

Standardized 5-level triage systems have
been developed and proven through research
to possess utility, validity, reliability, and
safety.
Time frames and are evidence based is a
consensus-based algorithm approach, which
utilizes longer time frames).

37. 

Conditions requiring immediate clinician
assessment. Any delay in treatment is
potentially life- or limb-threatening.
Includes conditions such as:








Airway or severe respiratory compromise.
Cardiac arrest.
Severe shock.
Symptomatic cervical spine injury.
Multisystem trauma.
Altered level of consciousness (LOC) (GCS < 10).
Eclampsia.
Extremely violent patient.

38. 

Conditions requiring clinician 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.
Chest pain.
Back pain.
GI bleed with unstable vital signs.

39. 

Conditions requiring clinician assessment
within 10 to 15 minutes of arrival.
Conditions include:










Stroke with deficit.
Severe asthma.
Abdominal pain in patients older than age 50.
Vomiting and diarrhea with dehydration.
Fever in infants younger than age 3 months.
Acute psychotic episode.
Severe headache.
Any pain greater than 7 on a scale of 10.
Any sexual assault.
Any neonate age 7 days or younger.

40. 

Conditions requiring clinician 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

41. 

Conditions requiring clinician assessment
within 1 hour of arrival.
Conditions include:
 Alert head injury without vomiting.
 Minor trauma.
 Vomiting and diarrhea in patient older than age 2 without




evidence of dehydration.
Earache.
Minor allergic reaction.
Corneal foreign body.
Chronic back pain.

42. 

Conditions requiring clinician assessment
within 2 hours of arrival.
Conditions include:
 Minor trauma, not acute.
 Sore throat.
 Minor symptoms.

Chronic abdominal pain

43. Approach to the Patient
 Understand and accept the basic anxieties of the
acutely ill or traumatized patient. Be aware of the
patient's fear of death, disablement, and isolation.
 Personalize the situation as much as possible. Speak, react, and




respond in a warm manner.
Give explanations on a level that the patient can grasp. An
informed patient can cope with psychological/physiologic stress
in a more positive manner.
Accept the rights of the patient and family to have and display
their own feelings.
Maintain a calm and reassuring manner—helps the emotionally
distressed patient or family to mobilize their psychological
resources.
Include the patient's family or significant others.
Continuation

44. Approach to the Patient
 Understand and support the patient's feelings
concerning loss of control (emotional, physical,
and intellectual).
 Treat the unconscious patient as if conscious.
Touch, call by name, and explain every procedure
that is done. Avoid making negative comments
about the patient's condition.
 Orient the patient to person, time, and place as soon as she is
conscious; reinforce by repeating this information.
 Bring the patient back to reality in a calm and reassuring way.
 Encourage the family, when possible, to orient the patient to
reality.

Be prepared to handle all aspects of acute illness
and trauma; know what to expect and what to do.
This alleviates the nurse's anxieties and increases

45. Approach to the Family
 Inform the family where the patient is, and give as much information
as possible about the treatment she is receiving.
 Consider allowing a family member to be present during the
resuscitation. Assign a staff person to the family member to explain
procedures and offer comfort.
 Recognize the anxiety of the family and allow them to talk about
their feelings. Acknowledge expressions of remorse, anger, guilt,
and criticism.
 Allow the family to relive the events, actions, and feelings preceding
admission to the ED.

46. Approach to the Family


Deal with reality as gently and quickly as
possible; avoid encouraging and supporting
denial.
Assist the family to cope with sudden and
unexpected death. Some helpful measures
include the following:
 Take the family to a private place.
 Talk to all of the family together so they can mourn
together.
 Assure the family that everything possible was done; inform
them of the treatment rendered.
 Avoid using euphemisms such as “passed on.” Show the
family that you care by touching, offering coffee.

47. Approach to the Family
 Allow family to talk about the deceased—permits




ventilation of feelings of loss. Encourage family to talk
about events preceding admission to the ED.
Encourage family to support each other and to express
emotions freely—grief, loss, anger, helplessness, tears,
disbelief.
Avoid volunteering unnecessary information (eg, patient
was drinking).
Avoid giving sedation to family members—may mask or
delay the grieving process, which is necessary to achieve
emotional equilibrium and prevent prolonged depression.
Be cognizant of cultural and religious beliefs and needs.

48. Approach to the Family
 Encourage family members to view the body if they wish—
to do so helps to integrate the loss (cover mutilated areas).
▪ Prepare the family for visual images and explain any legal
requirements.
▪ Go with family to see the body.
▪ Show acceptance of the body by touching to give family
permission to touch and talk to the body.
▪ Spend a few minutes with the family, listening to them.
▪ Allow the family some private time with the body, if
appropriate.

Encourage the ED staff to discuss among
themselves their reaction to the event to
share intense feelings for review and for
group support.

49. 
Pain is an unpleasant sensory and
emotional experience associated with
actual or potential tissue damage and is
also associated with significant morbidity.

Pain inhibits immune function and has
detrimental effects on cardiovascular,
respiratory, GI, and other body systems.

Pain may be somatic or visceral, acute or

50. 
Over 60% of patients report pain on arrival
at ED, making pain the most common
patient complaint. It is imperative to
adequately assess, monitor, and relieve
pain in the ED.

Significant evidence-practice gaps have
been identified with underestimation and
undertreatment of pain, despite available
clinical practice guidelines.

51. 
ABCD

Evaluate pain using the PQRST mnemonic

Assess pain score using a pain rating tool,
such as the verbal rating scale (VRS),
numeric rating scale (NRS), visual
analogue scale (VAS), Wong-Baker FACES
pain scale, FLACC (faces, legs, activity, cry,
and consolability) behavioral scale, or

52. Establish a supportive relationship with the
patient.
 Respect the patient's response to pain and its
management.
 Educate the patient regarding methods of
pain relief, preventive measures, and
expectations.
 Administer pharmaceutical and
nonpharmaceutical pain control.
 Monitor the patient's response to and
effectiveness of treatment.


53. 
Pain relief is a moral, humane, and
physiologic imperative.