Care of a client in the emergency department: Nursing

The role of a nurse in the emergency department, or ED, is to identify and respond to patients with potentially life-threatening conditions using a standardized triage process. Triage involves rapidly classifying patients based on the severity of their condition and then caring for the most critically ill first.

The triage process includes a primary survey, to identify emergent conditions, like hemorrhage or skull fractures, and manage them as they are identified; followed by a secondary survey, to identify urgent and nonurgent conditions and injuries, like a broken arm or leg wound.

Now the primary survey is the initial assessment of your trauma patient, that can be guided using the mnemonic ABCDE, which stands for Airway, Breathing, Circulation, Disability and Exposure. Your primary survey begins when you first see your patient.

If, during this time, you identify an obvious and significant external hemorrhage, your focus will shift from ABCDE to CABDE, meaning you should control the hemorrhage first before moving on with your assessment.

If no external hemorrhage is noted, you'll start your assessment with A, where you’ll assess alertness and airway patency. To determine alertness, assess your patient’s level of consciousness using the mnemonic AVPU. A is for alert, V is for responsiveness to voice, P is for responsiveness to pain, and U is for unresponsiveness.

For airway patency, look for signs of a compromised airway, like gasping, or agonal breaths, dyspnea, and facial or neck trauma. Be sure to identify airway obstructions, like secretions, emesis, an enlarged tongue, or foreign objects, like loose teeth or dentures.

For patients who are unable to keep their airway patent, prepare them for rapid sequence intubation. Also, if your patient is suspected of having a spinal cord injury, stabilize their cervical spine using a cervical collar or immobilization device.

Next, for B, you’ll assess breathing. Even with a patent airway, other problems can cause impaired ventilation and gas exchange, like broken ribs or flail chest, which happens when two or more contiguous ribs break in multiple places and detach from the sternum.

During this step, observe respiratory pattern, depth, and rate. Also auscultate lung sounds. Note the color of their skin, mucous membranes, and nail beds for signs of cyanosis caused by decreased oxygenation.

For patients with impaired breathing, give supplemental oxygen through a nonrebreather mask, provide rescue breaths using a bag-valve-mask with oxygen, or prepare them for intubation, as indicated. If your patient’s lung sounds are absent, prepare them for chest tube insertion.

Moving on to C, you’ll assess circulation and continue to control for hemorrhage, when present. You’ll palpate their carotid and femoral pulses, and, if absent, immediately initiate CPR and advanced life support measures. If pulses are found, assess the rhythm, quality and rate, and assess capillary refill.