EMERGENCY AND DISASTER NURSING
the normal patterns of life (or ecosystems)
TERMS USE:
Trauma - Intentional or unintentional
wounds/injuries on the human body from
particular mechanical mechanism that exceeds
the body’s ability to protect itself from injury
Emergency Management - traditionally
refers to care given to patients with urgent and
critical needs.
Triage - process of assessing patients to
determine management priorities.
First Aid - an immediate or emergency
treatment given to a person who has been
injured before complete medical and surgical
treatment can be secured.
BLS - level of medical care which is used for
patient with illness or injury until full medical
care can be given.
ACLS ADVANCE CARDIAC LIFE SUPPORT-
Set of clinical interventions for the urgent
treatment of cardiac arrest and often life
threatening medical emergencies as well as
the knowledge and skills to deploy those
interventions.
Defibrillation - Restoration of normal rhythm
to the heart in ventricular or atrial fibrillation
Disaster - Any catastrophic situation in which
pressured care environment
have been disrupted and extraordinary,
emergency interventions are required to save
and preserve human lives and/or the
environment.
Mass Casualty Incident - situation in which
the number of casualties exceeds the number
of resources.
Post Traumatic Stress Syndrome -
characteristic of symptoms after a
psychologically stressful event was out of
range of an normal human experience.
EMERGENCY – IT IS WHATEVER THE PATIENT
OR THE FAMILY CONSIDERS IT TO BE.
EMERGENCY NURSING - It is the nursing care
given to patients with urgent and critical needs
EMERGENCY NURSE - has a specialized
education, training, and experience to gain
expertise in assessing and identifying patients’
health care problems in crisis situations
 establishes priorities, monitors and
continuously assesses acutely ill and
injured patients, supports and attends to
families, supervises allied health
personnel, and teaches patients and
families within a time-limited, high-
DISASTER NURSING - a branch of
emergency nursing, it refers to nursing care
given to patients who are victims of disasters,
whether it is manmade or natural phenomena.
INCIDENT COMMAND SYSTEM - It is a
management tool for organizing personnel,
facilities, equipment, and communication for
any emergency situation.
INCIDENT COMMANDER - The head of the
incident command system
 He must be continuously informed of all
the activities and informed about any
deviation from the established plan
SCOPE AND PRACTICE OF EMERGENCY
NURSING
 The emergency nurse has had
specialized education, training, and
experience.
 The emergency nurse establishes
priorities, monitors and continuously
assesses acutely ill and injured patients,
 supports and attends to families,
supervises allied health personnel, and
teaches patients and families within a
time-limited, high-pressured care
environment.
 Nursing interventions are accomplished
interdependently, in consultation with or
under the direction of a licensed
physician.
 Appropriate nursing and medical
interventions are anticipated based on
assessment data.
 The emergency health care staff
members work as a team in performing
the highly technical, hands-on skills
required to care for patients in an
emergency situation.
 Patients in the ED have a wide variety of
actual or potential problems, and their
condition may change constantly.
 Although a patient may have several
diagnosis at a given time, the focus is on
the most life-threatening ones
ISSUES IN EMERGENCY NURSING CARE
 Emergency nursing is demanding
because of the diversity of conditions
and situations which are unique in the  Alleviate Suffering
ER.  Do No Further Harm
 Restore to Optimal Function
 Issues include legal issues, occupational
health and safety risks for ED staff, and
the challenge of providing holistic care in Golden Rules of Emergency Care
the context of a fast-paced, technology-
driven environment in which serious  Do’s
illness and death are confronted on a - Obtain Consent
daily basis. - Think of the Worst
- Respect Victim’s Modesty &
 The emergency nurse must expand his Privacy
or her knowledge base to encompass  Don’ts
recognizing and treating patients and - let the patient see his own injury
anticipate nursing care in the event of a - Make any unrealistic promises
mass casualty incident.
Guidelines in Giving Emergency Care
 Legal Issues Includes:
 A – Ask for help
 Actual Consent  I – Intervene
 Implied Consent  D – Do no Further Harm
 Parental Consent
 “Good Samaritan Law”
 Gives legal protection to the Stages of Crisis
rescuer who act in good faith and 1. Anxiety and Denial
are not guilty of gross negligence  encouraged to recognize and talk about
or willful misconduct. their feelings.
 asking questions is encouraged.
Focus of Emergency Care
 honest answers given
 Preserve or Prolong Life
  prolonged denial is not encouraged or  Support Staff C – Circulation
supported  Inpatient Unit Staff
- Monitor VS
2. Remorse and Guilt
 verbalize their feelings Emergency Action Principle - Maintain Vascular Access
3. Anger I. Survey the Scene
 way of handling anxiety and fear  Is the Scene Safe? - Direct Pressure
 allow the anger to be ventilated  What Happened? Estimated Blood Pressure
4. Grief  Are there any bystanders who can help?
 help family members work through their  identify as a trained first aider! SITE SBP
grief
 letting them know that it is normal and Radial ≥ 80
acceptable II. Do a Primary Survey - organization of
Core Competencies in Emergency Nursing approach so that immediate threats to life are
 Assessment rapidly identified and effectively manage.
 Priority Setting/Critical Thinking Skills
 Knowledge of Emergency Care
 Technical Skills Primary Survey Femoral ≥ 70
 Communication A - Airway/Cervical Spine

Assess and Intervene - Establish Patent Airway

Check for ABCs of life
- Maintain Alignment
 A – Airway
 B – Breathing - GCS ≤ 8 = Prepare Intubation Carotid ≥ 60
 C - Circulation
Team Members B – Breathing
 Rescuer - Assess Breath Sounds
 Emergency Medical Technician
 Paramedics - Observe for Chest Wall Trauma
 Emergency Medicine Physicians Control of Hemorrhage
- Prepare for chest decompression
 Incident Commander

D – Disability
- Evaluate LOC
- Re-evaluate clients LOC
- Use AVPU mnemonics
E – Exposure
- Remove clothing
- Maintain Privacy
- Prevent Hypothermia
III. Activate Medical Assistance
 Information to be Relayed:
• What Happened?
• Number of Persons Injured
• Extent of Injury and First Aid given
• Telephone number from where you’re
calling
IV. Do Secondary Survey
 Interview the Patient
S – Symptoms
A – Allergies
M – Medication
P – Previous/Present Illness
L – Last Meal Taken
E – Events Prior to Accident
 Check Vital Signs
V. Triage
 comes from the French word ”trier”,
meaning to sort
 process of assessing patients to
determine management priorities
Categories:
1. Emergent - highest priority,
conditions are life threatening and
need immediate attention
 Airway obstruction, sucking chest
wound, shock, unstable chest and
abdominal wounds, open fractures of
long bones
2. Urgent – have serious health problems
but not immediately life threatening
ones. Must be seen within 1 hour
 Maxillofacial wounds without airway
compromise, eye injuries, stable
abdominal wounds without evidence of
significant hemorrhage, fractures
3. Non-urgent – patients have episodic
illness than can be addressed within 24
hours without increased morbidity
 Upper extremity fractures, minor burns,
sprains, small lacerations without
significant bleeding, behavioral disorders
or psychological disturbances.
3. Non-urgent – patients have episodic
illness than can be addressed within 24
hours without increased morbidity
 Upper extremity fractures, minor burns,
sprains, small lacerations without
significant bleeding, behavioral disorders
or psychological disturbances.
  Psychological support needed  a condition when the respiration or
TRIAGE PRIORIT COLOR
CATEGOR Y
breathing pattern of an individual stops
Y FIRST AID to function, while the pulse and
IMMEDIA 1 RED Role of First Aid circulation may continue.
TE  Bridge the Gap Between the Victim and
DELAYED 2 YELLOW Causes: Choking, Electrocution, strangulation,
the Physician
MINIMAL 3 GREEN drowning and suffocation.
 Immediately start giving interventions
EXPECTA 4 BLACK
in pre-hospital setting
Field TRIAGE Value of First Aid Training
1. Immediate:  Self-help WAYS TO VENTILATE THE LUNGS
 Injuries are life-threatening but  Health for Others 1. MOUTH-TO-MOUTH = a quick, effective
survivable with minimal intervention. way to provide O2 and ventilation to the
 Preparation for Disaster
Individuals in this group can progress victim.
 Safety Awareness
rapidly to expectant if treatment is 2. MOUTH-TO-NOSE = recommended when
delayed. it is impossible to ventilate through the
2. Delayed: BASIC LIFE SUPPORT - an emergency victim’s mouth. (Trismus, mouth injury)
 Injuries are significant and require procedure that consists of recognizing 3. MOUTH-TO-NOSE and MOUTH = if the pt.
medical care, but can wait hours without respiratory or cardiac arrest or both the proper is an infant
threat to life or limb. Individuals in this application of CPR to maintain life until a victim 4. MOUTH-TO-STOMA = used if the pt. has
group receive treatment only after recovers or advance life support is available. a stoma; a permanent opening that
immediate casualties are treated. connects the trachea directly to the front
3. Minimal: Artificial Respiration of the neck.
 Injuries are minor and treatment can be  a way of breathing air to person’s lungs
delayed hours to days. Individuals in this For Rescue Breathing Alone:
when breathing ceased or stopped
group should be moved away from the  Rate is 10-12 breaths in ADULT
function.
main triage area.  (1.5 - 2 sec/breath) ( 1 breath every 4 to
4. Expectant: 5 secs)
 Injuries are extensive and chances of  Rate is 20 breaths for a CHILD and
survival are unlikely even with definitive INFANT
care. Respiratory Arrest  (1 – 1.5 sec/breath) ( 1 breath every 3
5. Fast-Track: secs)
 Approach of the steadily for
Assess for Shout and gently pinch Gently infant look for 1.5 – 2
Response shouting chest seconds
“are you look for rising look for
ok?” then chest rising chest rising
shake the
Table of Cardiopulmonary Resuscitation victim
Positionin Placed Supine on a firm and flat
for Adult, Child & Infant g surface
Adult Child Infant
Open the • Check for foreign bodies then
Compressi Lower half of Lower half Lower half
Airway remove using finger sweep
on Area the sternum of the of the
but not hitting sternum but sternum but • Head-tilt-chin-lift maneuver
the xiphoid not hitting not hitting • Jaw-thrust Maneuver
process: the xiphoid the xiphoid
measure up to process: process: 1 Assess for • Bring cheek over the mouth and
2 fingers from measure up finger width Breathing nose of the casualty
substernal to 1 finger below the • Look for chest movement
notch. from imaginary • Listen for breath sounds
substernal nipple line.
notch. • Feel for breathing on your
Depth Approximately Approximat Approximate cheek
1 ½ to 2 ely 1 to 1 ½ ly ½ to 1 The Casualty is NOT Breathing:
inches inches inch
How to Heel of 1 Heel of 1 2 fingers Go for  if someone responds to your
compress hand, other hand. (middle & Help shout for help send that person
hand on top. ring to phone for ambulance
fingertips)
Compressi 30:2 (1 or 2 30:2 (1 or 2 30:2 (1 or 2
 if you’re on your own, leave the
on- rescuers) rescuers) rescuers) casualty and make the phone
ventilation call for yourself
ratio * never leave if the patient has
Number of 5 cycles in 2 5 cycles in 2 5 cycles in 2 collapsed as a result of trauma or
cycles per minutes minutes minutes drowning or if the casualty is a child
minute Give 5 rescue breaths 2 rescue
Rescue breaths
Breaths Place pinch seal lips The Casualty is Breathing:
Procedur Infant(0-1yr) Child(1 Adult mouth over nose and around the
e -8 yrs) • Place in recovery position
the nose ventilate mouth and
and mouth via mouth blow
Safe Approach and assess situation
 • Before moving casualty remove any
objects safely from her pockets
• Kneel beside casualty, place arm nearest
at right angles, and then bend elbow
keeping the palm uppermost.
• Bring far arm across the casualty’s chest
and hold back of the casualty’s hand
against the nearest cheek
• With your other hand grasp the far thigh
just above the knee, then pull the
casualty towards you and on to his or
her side
CRITERIA FOR NOT STARTING CPR
- All patients in cardiac arrest receive
resuscitation unless:
1. The pt. has a valid DNR order
2. The pt. has signs of irreversible death:
rigor mortis, livor mortis, algor mortis,
decapitation
3. No physiological benefit can be expected
because the vital functions have
deteriorated despite maximal therapy
4. Witholding attempts to resuscitate in the
DR is appropriate for newly born infants
with:
- Confirmed gestation less than 23
weeks or birthweight less than
400 grams
- Anencephaly
When to Stop
 when the patient has spontaneous
breathing
 when the first aider is too exhausted to
continue
 when another first aider takes over
 when EMS arrives and takes over
When to STOP CPR:
S – SPONTANEOUS BREATH RESTORED
T – TURNED OVER THE MEDICAL SERVICES
O – OPERATOR IS EXHAUSTED TO CONTINUE
P – PHYSICIAN ASSUMES RESPONSIBILITY
COMPLICATIONS OF CPR:
 RIB FRACTURE
 STERNUM FRACTURE
 LACERATION OF THE LIVER OR SPLEEN
 PNEUMOTHORAX, HEMOTHORAX
CHAIN OF SURVIVAL
 EARLY ACCESS – early recognition of
cardiac arrest, prompt activation of
emergency services
 EARLY BLS – prevent brain damage,
buy time for the arrival of defibrillator
 EARLY DEFIBRILLATION - 7-10%
decrease per minute without
defibrillation
 EARLY ACLS – technique that attempts
to stabilize patient
AIRWAY OBSTRUCTION
KINDS OF AIRWAY OBSTRUCTION:
1. Anatomic Airway Obstruction
2. Mechanical Airway Obstruction
TYPES OF AIRWAY OBSTRUCTION
1. Partial Airway Obstruction with Good Air
Exchange
2. Partial Airway Obstruction with Poor Air
Exchange
3. Complete Airway Obstruction
Clinical Manifestations: UNIVERSAL DISTRESS
SIGNAL
(patient may clutch the neck between the
thumb and fingers), choking, stridor,
apprehensive appearance, restlessness.
CYANOSIS and LOSS of CONSCIOUSNESS
develop as hypoxia worsens.
MANAGEMENT FOR AIRWAY
OBSTRUCTION
HEIMLICH MANEUVER
(Subdiaphragmatic Abdominal Thrusts)
For Standing or sitting conscious patient:
• Stand behind the patient; wrap your
arms around the patient’s waist
• Make a FIST, placing thumb side of the
fist against the pt’s abdomen, in the
midline SLIGHTLY ABOVE the UMBILICUS
and WELL BELOW the XIPHOID PROCESS
• Make a quick INWARD and UPWARD
thrust. Each thrust is separated.
For patient lying (unconscious):
• position patient at the back (supine);
kneel astride the patient’s thigh
• Place HEEL of one HAND against the
pt’s abdomen, place the second hand
directly on the top of the fist.
• Make a quick UPWARD thrust
FINGER SWEEP: used only in unconscious adult
client
• Make a TONGUE-JAW LIFT. Opening the
pt’s mouth by grasping both tongue and
lower jaw between the thumb and
fingers, and lifting the mandible.
• Insert index finger of other hand to
scrape across the back of the throat
• Use a hooking action
CHEST THRUST: used only in patients in
advanced stages of pregnancy or in markedly
obese clients
a. Conscious Patient standing or sitting
• Stand behind the client with arms under
patient’s axilla to encircle patient’s chest
• Place thumb side of fist on the MIDDLE
of STERNUM, grasp with the other hand
and perform BACKWARD thrust until
foreign body is expelled.
MEASURES TO ESTABLISH AIRWAY
A. HEAD-TILT-CHIN-LIFT MANEUVER
B. JAW-THRUST MANEUVER
C. OROPAHRYNGEAL AIRWAY
D. ENDOTRACHEAL INTUBATION
Indications:
 To establish an airway for patients
cannot be adequately ventilated with an
oropharyngeal airway
 To bypass upper airway obstruction
 To permit connection to ambubag or
mechanical ventilator
 To prevent aspiration
 To facilitate removal of tracheobronchial
secretions
E. CRICOTHYROIDOTOMY
• a puncture or incision of the cricothyroid
membrane to establish an emergency
airway in certain emergency situations
where endotracheal intubation or
tracheostomy is not possible.
• indicated to pts. with trauma to head
and neck, and in allergic reaction
causing laryngeal edema
• use of gauge 11 needle or scalpel blade
Nursing Actions:
• Extend the neck. Place towel roll
beneath the shoulders
• Insert the needle at a 10 to 30 degree
caudal direction in the midline jest
above the upper part of the cricoid
cartilage
• Listen for air passing back and forth
• Direct the needle downward and
posteriorly, and tape it.
INJURIES TO HEAD, SPINE, AND FACE
A. HEAD INJURIES
1. OPEN HEAD INJURY – skull is fractured
2. CLOSED HEAD INJURY – skull is intact
3. CONCUSSION – temporary loss of
consciousness that results in transient
interruption if the brain’s normal
functioning
4. CONTUSSSION – bruising of the brain
tissue
 5. INTRACRANIAL HEMORRHAGE –
significant bleeding into a space or
potential space between the skull and
the brain
a. Epidural hematoma
 the most serious type of
hematoma; forms rapidly and
results from arterial bleeding
 forms between the dura and the
skull from a tear int the meningeal
area
b. Subdural hematoma
 forms slowly and results from a
venous bleed
 a surgical emergency
c. Intracerebral hemorrhage
 bleeding directly into the brain
matter
ALERT: Assume cervical spine fracture for
any patient with a significant head injury,
until proven otherwise.
PRIMARY ASSESSMENT: Assess for ABC
SECONDARY ASSESSMENT:
 Change in LOC – most sensitive
indicator in the pt’s condition
 CUSHING’S TRIAD ( bradypnea,
bradycardia, widened pulse pressure) –
indicating increased intracranial
pressure
 unequal or unresponsive pupils;
impaired vision
 Battle’s sign – bluish discoloration of the
mastoid, indicating a possible BASAL
SKULL FRACTURE
 Rhinorrhea or otorrhea – indicative of
CSF leak
 Periorbital Ecchymosis – indicates
anterior basilar fracture
ALERT: If basilar skull fracture or severe
midface fractures are suspected, a
nasogastric tube(NGT) is CONTRAINDICATED!
MANAGEMENT:
 Open airway by Jaw-Thrust Manuever,
suction orally if needed
 Administer high flow oxygen: most
common death is CEREBRAL ANOXIA
 In general, hyperventilate the patient to
20-25 bpm, causing cerebral
vasoconstriction and minimizing cerebral
edema
 Apply a bulky, loose dressing; don’t
apply pressure
 IV line of PNSS or Plain LR
 prepare to manage seizures
 maintain normothermia
 Medications:
a. Diazepam
b. Steroids
c. Mannitol
 Prepare of immediate surgery if pt.
shows evidence of neurologic
deterioration
B. SKULL FRACTURES
• SIMPLE – closed
• COMPOUND – open
• LINEAR Fx – common hairline break, w/o
displacement of structure
• COMMINUTED Fx – splinters or crushes
the bone in several fragments
• DEPRESSED Fx – pushes the bone
toward the brain
• CRANIAL VAULT Fx – top of the head
• BASILAR Fx – base of the skull and
frontal sinuses
ALERT:
• Damage to the brain is the first concern,
it is considered a neurosurgical condition
• In children, skull’s thinness and
elasticity allows a depression w/o a
break in the bone
CAUSES: Traumatic blows to the head,
VA, severe beatings
• S/Sx: scalp wounds, agitation and
irritability, loss of consciousness, labored
breathing, abnormal deep tendon
reflexes, altered pupillary and moor
response
IF CONSCIOUS: complains of persistent
localized headache
IF JAGGED BONE FRAGMENTS: may cause
cerebral
bleeding
HALO SIGN – blood-tinged spot surrounded
by lighter
 ring  don’t give narcotics or sedative • Flattening of the cheek and loss of
IF SPHENOIDAL Fx: damages the optic nerve  assist in surgery, maintaining sterile sensation below the orbit – indicates
and may technique ZYGOMA (cheekbone) FX
cause BLINDNESS • Malocclussion of teeth, trismus –
IF TEMPORAL Fx: may cause unilateral C. CERVICAL SPINE INJURIES indicative of MAXILLA FX
deafness or PRIMARY ASSESSMENT: PRIMARY INTERVENTIONS:
facial paralysis • immediate immobilization of the spine  Insertion of oral airway or intubation
• A B C ( Intercoastal paralysis w/  Nasopharyngeal airway should only be
TREATMENT: diapragmatic breathing) used if no evidence of nasal fracture or
For LINEAR FRACTURES: rhinorrhea
 supporative (mild analgesics) SUBSEQUENT ASSESSMENT:  Apply bulky, loose dressing; apply ice to
 cleaning and debridement of wounds • Hypotension, bradycardia, hypothermia areas of swelling
 If conscious: observed for 4 hours; if not, - suggests SPINAL SHOCK
admit for evaluation • Total sensory loss and motor paralysis
 if VS stable, may go home with below the level of injury
instruction sheet MANAGEMENT:
For VAULT and BASILAR FRACTURES:  Nasotracheal intubation
 Craniotomy to remove fragemnts  initaite IV access, monitor blood gas
 anti-biotics  indwelling urinary catheterization
 Dexamethasone  prepare to manage seizures
 Osmotic Diuretics (MANNITOL) if  Meds: High dose steroids and diazepam
increased ICP is present
NURSING CONSIDERATIONS: D. MAXILLOFACIAL TRAUMA
 maintain patent airway; nasal airway PRIMARY ASSESSMENT:
contraindicated to basilar fx • Immobilization of spine while
 support with O2 administration performing assessment
 suction pt. through mouth not nose if • ABC – (tongue swelling, bleeding,
CSF leak is present broken or missed teeth)
 RHINORRHEA – wipe it, don’t let him SUBSEQUENT ASSESSMENT:
blow it! • Paralysis if the upward gaze – indicative
of INFERIOR ORBIT FX
 OTORRHEA – cover it lightly with sterile
• Crepitus on nose – indicates nasal
gauze, don’t pack it!
fracture
 Position head on side
 Maintain a supine position with bed
elevated to 30 degrees