Emergency and Disaster Nursing
Most patients with life-threatening or potentially life-threatening problems arrive at the hospital through the
emergency department (ED).
Triage refers to the process of rapidly determining the acuity of the patient’s problem, and it represents one of
the most important assessment skills needed by the emergency nurse.
The triage process is based on the premise that patients who have a threat to life, vision, or limb should be
treated before other patients.
o A triage system categorizes patients so that the most critical ones are treated first.
o The Emergency Severity Index (ESI) is a 5-level triage system that incorporates concepts of
illness severity and resource utilization to determine who should be treated first.
After the initial assessment to determine the presence of actual or potential threats to life, appropriate
interventions are initiated for the patient’s condition.
The primary survey focuses on airway, breathing, circulation, and disability and serves to identify life-
threatening conditions so that appropriate interventions can be initiated.
If life-threatening conditions related to airway, breathing, circulation, and disability are identified
at any point during the primary survey, interventions are started immediately and before
proceeding to the next step of the survey.
Airway with cervical spine stabilization and/or immobilization:
Primary signs and symptoms in a patient with a compromised airway include dyspnea,
inability to vocalize, presence of foreign body in the airway, and trauma to the face or
Airway maintenance should progress rapidly from the least to the most invasive method
and includes opening the airway using the jaw-thrust maneuver, suctioning and/or
removal of foreign body, insertion of a nasopharyngeal or oropharyngeal airway, and
The cervical spine must be stabilized and/or immobilized in any patient with face, head,
or neck trauma and/or significant upper torso injuries.
Breathing alterations are caused by many conditions (e.g., fractured ribs, pneumothorax,
allergic reactions, pulmonary emboli, asthma) resulting in dyspnea, paradoxical or
asymmetric chest wall movement, decreased or absent breath sounds, cyanosis,
tachycardia, and hypotension.
High-flow oxygen (100%) via a non-rebreather mask should be administered and the
patient’s response monitored. Life-threatening conditions may require bag-valve-mask
ventilation with 100% oxygen and intubation.
A central pulse is checked because peripheral pulses may be absent as a result of direct
injury or vasoconstriction.
Skin is assessed for color, temperature, and moisture.
Altered mental status and delayed capillary refill are the most significant signs of shock.
Two large-bore IV catheters should be inserted and aggressive fluid resuscitation initiated
using normal saline or lactated Ringer’s solution.
The degree of disability is measured by the patient’s level of consciousness.
A simple mnemonic can be used: AVPU: A = alert, V = responsive to voice, P = responsive to pain, and U = unresponsive.
The Glasgow Coma Scale is used to further assess the arousal aspect of the patient’s
Pupils are assessed for size, shape, response to light, and equality.
The secondary survey is a brief, systematic process that is aimed at identifying all injuries.
Exposure/environmental control. All trauma patients should have their clothes removed so that a
thorough physical assessment can be performed.
Full set of vital signs/five interventions/facilitate family presence:
A complete set of vital signs, including blood pressure, heart rate, respiratory rate, and
temperature, is obtained after the patient is exposed.
Five interventions: 1) ECG monitoring is initiated; 2) pulse oximetry is initiated; 3) an
indwelling catheter is inserted; 4) an orogastric or a nasogastric tube is inserted; 5) blood
for laboratory studies is collected.
Family presence: family members who wish to be present during invasive procedures
and resuscitation view themselves as active participants in the care process and their
presence should be supported.
Give comfort measures. Pain management strategies should include a combination of
pharmacologic and nonpharmacologic measures.
History and head-to-toe assessment:
A thorough history of the event, illness, injury is obtained from the patient, family, and
A thorough head-to-toe assessment is necessary.
Inspect the posterior surfaces. The trauma patient should be logrolled (while maintaining cervical
spine immobilization) to inspect the posterior surfaces.
All patients should be evaluate