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Principles of Emergency Nursing | 마이메르시 MyMerci
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Principles of Emergency Nursing

NCLEX Review Guide: Emergency Nursing

Foundations of Emergency Nursing

Triage Principles

  • Triage is a systematic process of sorting patients based on acuity level and resource needs. The Emergency Severity Index (ESI) uses a five-level system where Level 1 represents patients requiring immediate life-saving interventions and Level 5 represents non-urgent conditions.
  • Primary assessment in triage follows the ABCDE approach: Airway, Breathing, Circulation, Disability, and Exposure, which provides a standardized method for quickly identifying life-threatening conditions.

Key Points

  • Always prioritize patients with airway, breathing, or circulation problems regardless of arrival time.
  • Reassessment is a critical component of triage; patient status can change rapidly in emergency settings.

Clinical Scenario

You have four patients arrive simultaneously: a 65-year-old with chest pain and diaphoresis, a 10-year-old with a fever of 101°F, a 45-year-old with a deep laceration, and a 25-year-old with respiratory distress. The patient with respiratory distress would be triaged first (ESI Level 2), followed by the patient with chest pain (ESI Level 2), the laceration (ESI Level 3), and finally the fever (ESI Level 4).

Disaster Management

  • Disaster triage differs from everyday triage and typically employs the START method (Simple Triage And Rapid Treatment), which categorizes patients as Immediate (red), Delayed (yellow), Minor (green), or Expectant/Deceased (black).
  • Mass casualty incidents require a shift from providing optimal care to each patient to providing the greatest good for the greatest number of patients, a concept known as crisis standards of care.

Key Points

  • In disaster situations, resource allocation becomes a primary consideration in treatment decisions.
  • Emergency nurses must understand both their facility's emergency operations plan and their role in community disaster response.

Critical Emergency Conditions

Shock States

  • Shock is a state of inadequate tissue perfusion that can rapidly progress to irreversible organ damage and death. The four main categories are hypovolemic, cardiogenic, distributive (including septic, anaphylactic, and neurogenic), and obstructive shock.
  • Early recognition of shock is crucial and includes assessment for subtle signs such as restlessness, anxiety, slight decreases in blood pressure, and increased respiratory rate before more obvious signs like hypotension develop.

Comparison of Shock Types

Type Cause Key Assessment Findings Primary Interventions
Hypovolemic Fluid loss (blood, plasma, etc.) Tachycardia, hypotension, decreased urine output, cool/clammy skin Fluid resuscitation, blood products, hemorrhage control
Cardiogenic Pump failure Jugular venous distention, pulmonary edema, S3 heart sound Inotropic support, preload/afterload reduction, treat underlying cause
Distributive Vasodilation (sepsis, anaphylaxis) Warm, flushed skin (early), normal/increased cardiac output initially Fluid resuscitation, vasopressors, source control (for sepsis)
Obstructive Mechanical obstruction to circulation Beck's triad (cardiac tamponade), pulsus paradoxus, JVD Remove obstruction (pericardiocentesis, thrombolytics for PE)

Key Points

  • Regardless of shock type, initial management includes ensuring adequate oxygenation and establishing IV access for fluid resuscitation.
  • Serial lactate levels are an important marker of tissue perfusion and should be monitored to evaluate response to treatment.

Do NOT delay fluid resuscitation in suspected septic shock while waiting for laboratory confirmation. Each hour delay in appropriate antibiotic administration increases mortality by approximately 7.6%.

Cardiac Emergencies

  • Acute Coronary Syndrome (ACS) encompasses a spectrum of conditions including unstable angina, NSTEMI, and STEMI, all resulting from decreased coronary blood flow. Time-sensitive interventions are critical, following the principle "time is muscle."
  • Recognition of life-threatening dysrhythmias requires systematic ECG interpretation, with immediate intervention for pulseless ventricular tachycardia, ventricular fibrillation, asystole, and pulseless electrical activity.

Memory Aid: MONA for ACS Initial Treatment

  • Morphine (or other analgesic)
  • Oxygen (if saturation <94%)
  • Nitroglycerin
  • Aspirin

Note: Current guidelines emphasize that oxygen should only be administered for hypoxemia (SpO2 <94%).

Key Points

  • A 12-lead ECG should be obtained within 10 minutes of arrival for any patient with suspected ACS.
  • Recognize that women, elderly patients, and those with diabetes may present with atypical symptoms of ACS, such as fatigue, dyspnea, or epigastric discomfort.

Respiratory Emergencies

  • Respiratory emergencies require rapid assessment and intervention to prevent decompensation. Key conditions include status asthmaticus, COPD exacerbation, pulmonary embolism, pneumonia, and tension pneumothorax.
  • Differentiation between respiratory distress and respiratory failure is crucial; failure indicates decompensation and potential need for mechanical ventilation. Signs of impending respiratory failure include altered mental status, paradoxical breathing, and severe accessory muscle use.

    Procedure: Emergency Needle Decompression for Tension Pneumothorax

  1. Identify tension pneumothorax (decreased breath sounds, tracheal deviation, JVD, hypotension, hypoxia)
  2. Locate the 2nd intercostal space at the midclavicular line on the affected side
  3. Cleanse the area with antiseptic solution if time permits
  4. Insert a large-bore needle (14-16 gauge) perpendicular to the chest wall, just superior to the 3rd rib
  5. Listen for a rush of air confirming successful decompression
  6. Secure the catheter and prepare for chest tube placement

Key Points

  • Continuous waveform capnography is valuable for monitoring both intubated and non-intubated patients with respiratory distress.
  • Position patients with respiratory distress in high Fowler's position unless contraindicated.

Never delay needle decompression for a suspected tension pneumothorax in a deteriorating patient. This is a clinical diagnosis that requires immediate intervention before radiographic confirmation.

Trauma Management

Primary and Secondary Survey

  • The primary survey follows the ABCDE framework with life-saving interventions performed simultaneously with assessment. Critical interventions include airway management with c-spine protection, oxygen administration, hemorrhage control, and fluid resuscitation.
  • The secondary survey is a comprehensive head-to-toe assessment conducted after the primary survey and stabilization. It includes vital signs, neurological assessment, detailed examination of all body systems, and reassessment of interventions from the primary survey.

Key Points

  • The primary survey should be repeated frequently in unstable trauma patients as their condition can change rapidly.
  • Maintain a high index of suspicion for internal bleeding in trauma patients with normal vital signs but mechanism for significant injury (compensated shock).

Traumatic Brain Injury (TBI)

  • TBI management focuses on preventing secondary brain injury by maintaining cerebral perfusion pressure (CPP) and controlling intracranial pressure (ICP). The key principle is to prevent hypoxia and hypotension, which can dramatically worsen outcomes.
  • Assessment includes the Glasgow Coma Scale (GCS), pupillary response, motor function, and monitoring for signs of increasing ICP such as Cushing's triad (hypertension, bradycardia, and irregular respirations).

Memory Aid: Glasgow Coma Scale

Eyes: 1-4 points

Verbal: 1-5 points

Motor: 1-6 points

Remember: "Eyes, Verbal, Motor" = 4, 5, 6 (maximum points)

Key Points

  • Maintain systolic BP >90 mmHg and oxygen saturation >90% to ensure adequate cerebral perfusion in TBI patients.
  • Serial neurological assessments are essential to detect deterioration; changes in GCS of 2 or more points warrant immediate physician notification.

Avoid hyperventilation in TBI patients unless there are signs of herniation. Prophylactic hyperventilation can cause cerebral vasoconstriction and worsen ischemic injury.

Hemorrhage Control

  • Hemorrhage remains the most preventable cause of death in trauma. The hemorrhage control sequence follows: direct pressure, pressure dressings, tourniquets for extremities, wound packing for junctional injuries, and hemostatic agents.
  • Damage control resuscitation employs balanced blood product administration (1:1:1 ratio of PRBCs, plasma, and platelets), permissive hypotension, and limited crystalloid use to prevent dilutional coagulopathy and hypothermia.

Key Points

  • Apply tourniquets 2-3 inches proximal to the wound, not over joints, and tighten until bleeding stops.
  • Document tourniquet application time; prolonged application (>2 hours) increases risk of compartment syndrome and tissue loss.

Toxicological Emergencies

Toxidrome Recognition

  • Toxidromes are constellations of signs and symptoms that suggest specific classes of poisoning. Recognition of these patterns can guide initial management before laboratory confirmation of the specific toxin.
  • Common toxidromes include cholinergic (organophosphates, carbamates), anticholinergic (antihistamines, tricyclic antidepressants), sympathomimetic (cocaine, amphetamines), opioid (heroin, fentanyl), and sedative-hypnotic (benzodiazepines, barbiturates).

Common Toxidromes

Toxidrome Vital Signs Pupils Mental Status Other Findings
Anticholinergic Hyperthermia, tachycardia, hypertension Dilated Agitation, hallucinations, delirium Dry mucous membranes, flushed skin, urinary retention, decreased bowel sounds
Cholinergic Bradycardia, variable BP Constricted Confusion, seizures, coma SLUDGE (Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis)
Opioid Respiratory depression, bradycardia, hypotension Miosis (pinpoint) Sedation, coma Decreased bowel sounds, hypothermia
Sympathomimetic Tachycardia, hypertension, hyperthermia Dilated Agitation, paranoia, psychosis Diaphoresis, tremors, hyperreflexia

Key Points

  • The classic triad of opioid overdose is respiratory depression, CNS depression, and miosis (pinpoint pupils).
  • Naloxone should be titrated to adequate respiratory function, not full consciousness, to prevent acute withdrawal and agitation.

Decontamination Principles

  • Gastrointestinal decontamination methods include activated charcoal, gastric lavage, and whole bowel irrigation. Activated charcoal is most effective when administered within 1 hour of ingestion and is contraindicated for caustic substances, hydrocarbons, and in patients with decreased mental status without airway protection.
  • External decontamination for chemical exposures requires a systematic approach including removal of clothing (which removes 85-90% of contaminants), copious irrigation with water or saline, and special considerations for specific agents (e.g., water-reactive chemicals).

Key Points

  • Staff safety is paramount during decontamination; appropriate personal protective equipment must be used.
  • Syrup of ipecac is no longer recommended for routine use in poisoning management.

Always protect the airway before administering activated charcoal to patients with decreased level of consciousness or at risk for seizures to prevent aspiration pneumonitis.

Commonly Confused Concepts

Differentiating Shock Types

Distinguishing Features of Different Shock Types

Parameter Hypovolemic Cardiogenic Distributive Obstructive
Preload (CVP) Decreased Increased Decreased Increased
Cardiac Output Decreased Decreased Increased (early) then decreased Decreased
SVR Increased Increased Decreased Increased
Skin Cool, clammy Cool, clammy Warm, flushed (early) Cool, clammy
JVD Flat neck veins Present Absent Present
Primary Treatment Volume replacement Improve contractility, reduce workload Vasopressors, volume Remove obstruction

Key Points

  • Shock can be mixed type; for example, septic shock often has components of both distributive and hypovolemic shock.
  • Fluid responsiveness is an important parameter to assess in all shock types to guide resuscitation.

Stroke vs. Hypoglycemia vs. Postictal State

Differentiating Features

Feature Acute Stroke Hypoglycemia Postictal State
Onset Sudden, focal deficits Gradual, may worsen over minutes Following witnessed or suspected seizure
Neurological Findings Focal deficits (one-sided weakness, aphasia, visual changes) Global dysfunction, may mimic stroke Confusion improving over time, may have focal deficits (Todd's paralysis)
Associated Symptoms Headache (hemorrhagic), nausea, vomiting Diaphoresis, tremor, hunger, palpitations Muscle soreness, tongue biting, urinary incontinence
Vital Signs Often hypertensive Normal or increased HR, normal BP Initially tachycardic, may normalize
Response to Intervention No immediate improvement with glucose Rapid improvement with glucose administration Gradual improvement with time

Key Points

  • Always check blood glucose in patients with altered mental status before administering stroke treatments.
  • Todd's paralysis can persist for up to 24 hours after a seizure, mimicking stroke symptoms.

Never delay checking blood glucose in a patient with altered mental status or apparent stroke symptoms. Hypoglycemia is a readily reversible cause that can mimic stroke presentation.

STEMI vs. Pericarditis vs. Aortic Dissection

Differentiating Features of Chest Pain Emergencies

Feature STEMI Pericarditis Aortic Dissection
Pain Character Pressure, squeezing, heaviness Sharp, pleuritic, positional Tearing, ripping, severe, "worst ever"
Pain Location Retrosternal, may radiate to arm/jaw Precordial, may radiate to trapezius Anterior chest or back, may migrate
Associated Symptoms Diaphoresis, nausea, SOB Fever, recent viral illness Syncope, neurological deficits, pulse deficits
Exacerbating Factors Exertion, stress Lying flat, deep breathing Hypertension
ECG Findings ST-segment elevation in contiguous leads Diffuse ST elevation, PR depression Normal or nonspecific; LVH from hypertension
Physical Exam May be normal Friction rub BP or pulse differentials, murmur of AI

Key Points

  • Aortic dissection is a contraindication to thrombolytic therapy; misdiagnosis can be fatal.
  • Check blood pressure in both arms for patients with suspected aortic dissection; a difference >20 mmHg is suggestive.

Study Tips for Emergency Nursing

Prioritization Frameworks

  • Master the ABCs as your primary framework for prioritization. Always address life-threatening issues in this sequence, with airway taking absolute precedence.
  • For multiple patients, use the Nursing Process (Assessment, Diagnosis, Planning, Implementation, Evaluation) and Maslow's Hierarchy to determine which needs must be addressed first.

Memory Aid: Prioritization Rules

  • Airway always comes first
  • Breathing problems are next
  • Circulation issues follow
  • Disability (neurological status) comes after ABC
  • Exposure/Environmental controls complete the primary assessment

Remember: "Airway Before Circulation, Disability Evaluation"

Key Points

  • When answering NCLEX questions about multiple patients, remember that unstable patients take priority over stable patients regardless of diagnosis.
  • Practice categorizing interventions as independent nursing actions versus those requiring provider orders.

Critical Lab Values in Emergency

  • Memorize normal ranges and critical values for common emergency labs including cardiac markers, coagulation studies, electrolytes, and arterial blood gases.
  • Understand the clinical significance of abnormal values and the appropriate nursing interventions required for critical results.

Memory Aid: Critical Lab Values

  • Potassium: <3.0 or >6.0 mEq/L (cardiac concerns)
  • Sodium: <120 or >160 mEq/L (neurological concerns)
  • Glucose: <40 or >500 mg/dL
  • Calcium: <6.0 or >13.0 mg/dL
  • Hemoglobin: <7 g/dL (consider transfusion)
  • WBC: >20,000 (severe infection)
  • Platelets: <20,000 (bleeding risk)
  • Troponin: Any elevation (cardiac injury)

Key Points

  • Trends in lab values are often more important than single values.
  • Always correlate lab values with the patient's clinical presentation.

Medication Administration in Emergencies

  • Focus on high-alert medications commonly used in emergency settings including vasopressors, antiarrhythmics, anticoagulants, thrombolytics, and rapid sequence intubation drugs.
  • Understand the critical nursing considerations for emergency medications: proper dosing, administration routes, monitoring parameters, and potential adverse effects requiring immediate intervention.

Memory Aid: PEERS for Emergency Medication Administration

  • Preparation (right drug, dose, dilution)
  • Equipment (IV pumps, monitoring devices)
  • Effects (expected therapeutic outcomes)
  • Risks (adverse effects to monitor for)
  • Special considerations (incompatibilities, titration parameters)

Key Points

  • Vasoactive medications should always be administered via a central line when possible and with continuous cardiac monitoring.
  • Double-check high-alert medications with another nurse before administration, even in emergency situations.

Vasopressors that extravasate can cause severe tissue necrosis. Monitor IV sites frequently and ensure a well-functioning IV before administration.

Self-Assessment

Quick Knowledge Check

Test Your Knowledge

  1. Which shock state is characterized by decreased preload, decreased cardiac output, and increased SVR?
    Hypovolemic shock
  2. What is the most appropriate initial intervention for a patient with tension pneumothorax?
    Needle decompression at the 2nd intercostal space, midclavicular line
  3. Which toxidrome presents with pinpoint pupils, respiratory depression, and decreased level of consciousness?
    Opioid toxidrome
  4. What is the correct sequence for the primary survey in trauma?
    Airway with c-spine protection, Breathing, Circulation, Disability, Exposure
  5. In which situation would activated charcoal be contraindicated?
    Caustic substance ingestion, hydrocarbon ingestion, or in patients with unprotected airways

Common NCLEX Pitfalls in Emergency Nursing

  • Focusing on the diagnosis rather than the presenting symptoms when prioritizing care
  • Selecting interventions that address the most dramatic symptoms rather than the most life-threatening
  • Choosing complex interventions before basic assessments are completed
  • Failing to recognize subtle signs of deterioration in seemingly stable patients
  • Selecting independent nursing interventions when the question is asking for collaborative actions

Study Progress Checklist











Remember, emergency nursing requires quick thinking and decisive action based on sound clinical knowledge. The ability to rapidly prioritize interventions while maintaining attention to detail is critical. Trust your assessment skills, follow protocols, and always be prepared to adapt to changing patient conditions. You've got this!

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