Emergency Nursing & Trauma
1. What systems are used for triage in the emergency department?
Triage: used to sort patients into groups based on the severity of their health problems
and the immediacy with which these problems must be treated; used for rapid
assessment and decision-making preferably in less than 5 minutes
Three Category Scale
Categorizes patients as emergent, urgent, or nonurgent
Emergency Severity Index
Assigns patients into 5 levels based on acuity and resource need
o Level 1- resuscitation
o Level 2- emergent
o Level 3- urgent
o Level 4- less urgent
o Level 5- nonurgent
Canadian Triage & Acute Scale
Assigns patients into 5 levels and includes time parameters for how frequently
patients are reassessed
o Level 1- resuscitation + continuous nursing surveillance
o Level 2- emergent + reassessed every 15 minutes
o Level 3- urgent + reassessed every 30 minutes
o Level 4- less urgent + reassessed every 60 minutes
o Level 5- nonurgent + reassessed every 120 minutes
Triage Bypass
Moves patient directly to an open bed in the ED to reduce waiting times
Receiving nurse performs initial assessment & vital signs
Team Triage
Triage nurse works with a physician or APN within the triage area
Can move patients to diagnostics and possible discharge without fully admission
to the ED
,2. What are the components (assessment and interventions) of the primary and
secondary survey?
Primary Assessment
Focuses on stabilizing life/limb threatening conditions; rapid assessment
o Airway- ensure airway is patent
o Breathing- provide adequate ventilation
o Circulation-restore cardiac output, control hemorrhage, prevent & treat
shock
o Disability- assess neurologic function using the Glascow Coma Scale or
AVPU mnemonic
Alert
Verbal responsiveness
Pain responsiveness
Unresponsive
o Exposure- undress to assess any wounds or areas of injury
Secondary Assessment
A more throughout assessment that focuses on diagnosis & treatment
Health history
Head-to-toe assessment
Diagnostics & lab testing
Monitoring devices
Splinting fractures
Wound care
3. What methods should the nurse utilize to determine neurologic function in a client
who experienced a trauma?
Glascow Coma Scale
Assesses neurological status in acute medical or trauma patients
Contains 3 components
o Eye opening response
o Verbal response
o Motor response
A sore of ≤ 8 indicates a comatose state
, 4. What are the different causes and types of traumas?
Trauma: an intentional or unintentional wound or injury inflicted on the body from a
mechanism against which the body cannot protect itself
Multiple Trauma: a single catastrophic event that causes life-threatening injuries to at
least two distinct organs or organ systems
Triad of mortality
o Hypothermia
o Metabolic acidosis
o Coagulopathy
Types
Blunt- injury of the body by forceful impact, falls, or physical attack with a dull
object
Penetrating- involves an object or surface piercing the skin, causing an open
wound
Management
Establish airway and ventilation
Control hemorrhage
Prevent and treat hypovolemic shock
Assess for head & neck injuries
Evaluate for other injuries
Splint fractures and reassess pulses & neurovascular status (if applicable)
Perform secondary assessment and diagnostic studies
5. What are the clinical manifestations associated with abdominal trauma?
Assessment & Diagnostic Findings
Gross injuries
o Bruises, abrasions, or penetrating trauma
Absent bowel sounds
Internal hemorrhage
o Blueish discoloration of back and flanks
o Hypotension & other signs of shock
Intraperitoneal injury
o Tenderness or rebound tenderness
o Guarding
o Abdominal distension/rigidity
o Referred pain
1. What systems are used for triage in the emergency department?
Triage: used to sort patients into groups based on the severity of their health problems
and the immediacy with which these problems must be treated; used for rapid
assessment and decision-making preferably in less than 5 minutes
Three Category Scale
Categorizes patients as emergent, urgent, or nonurgent
Emergency Severity Index
Assigns patients into 5 levels based on acuity and resource need
o Level 1- resuscitation
o Level 2- emergent
o Level 3- urgent
o Level 4- less urgent
o Level 5- nonurgent
Canadian Triage & Acute Scale
Assigns patients into 5 levels and includes time parameters for how frequently
patients are reassessed
o Level 1- resuscitation + continuous nursing surveillance
o Level 2- emergent + reassessed every 15 minutes
o Level 3- urgent + reassessed every 30 minutes
o Level 4- less urgent + reassessed every 60 minutes
o Level 5- nonurgent + reassessed every 120 minutes
Triage Bypass
Moves patient directly to an open bed in the ED to reduce waiting times
Receiving nurse performs initial assessment & vital signs
Team Triage
Triage nurse works with a physician or APN within the triage area
Can move patients to diagnostics and possible discharge without fully admission
to the ED
,2. What are the components (assessment and interventions) of the primary and
secondary survey?
Primary Assessment
Focuses on stabilizing life/limb threatening conditions; rapid assessment
o Airway- ensure airway is patent
o Breathing- provide adequate ventilation
o Circulation-restore cardiac output, control hemorrhage, prevent & treat
shock
o Disability- assess neurologic function using the Glascow Coma Scale or
AVPU mnemonic
Alert
Verbal responsiveness
Pain responsiveness
Unresponsive
o Exposure- undress to assess any wounds or areas of injury
Secondary Assessment
A more throughout assessment that focuses on diagnosis & treatment
Health history
Head-to-toe assessment
Diagnostics & lab testing
Monitoring devices
Splinting fractures
Wound care
3. What methods should the nurse utilize to determine neurologic function in a client
who experienced a trauma?
Glascow Coma Scale
Assesses neurological status in acute medical or trauma patients
Contains 3 components
o Eye opening response
o Verbal response
o Motor response
A sore of ≤ 8 indicates a comatose state
, 4. What are the different causes and types of traumas?
Trauma: an intentional or unintentional wound or injury inflicted on the body from a
mechanism against which the body cannot protect itself
Multiple Trauma: a single catastrophic event that causes life-threatening injuries to at
least two distinct organs or organ systems
Triad of mortality
o Hypothermia
o Metabolic acidosis
o Coagulopathy
Types
Blunt- injury of the body by forceful impact, falls, or physical attack with a dull
object
Penetrating- involves an object or surface piercing the skin, causing an open
wound
Management
Establish airway and ventilation
Control hemorrhage
Prevent and treat hypovolemic shock
Assess for head & neck injuries
Evaluate for other injuries
Splint fractures and reassess pulses & neurovascular status (if applicable)
Perform secondary assessment and diagnostic studies
5. What are the clinical manifestations associated with abdominal trauma?
Assessment & Diagnostic Findings
Gross injuries
o Bruises, abrasions, or penetrating trauma
Absent bowel sounds
Internal hemorrhage
o Blueish discoloration of back and flanks
o Hypotension & other signs of shock
Intraperitoneal injury
o Tenderness or rebound tenderness
o Guarding
o Abdominal distension/rigidity
o Referred pain
