Principles of Emergency & Critical Care Nursing - Cheat Sheet
Your last-minute revision companion for rapid-fire review of triage, primary survey, hemodynamics, and critical priorities in emergency and ICU nursing. Master ABCDE, know your numbers, and nail the priority hierarchy.
TRIAGE: Acuity-Based Sorting
Common values
Value
Immediate
Symbol
P1
Quantity
Emergent care window
Value
30–60 minutes
Symbol
P2
Quantity
Urgent care window
Important facts
- Triage sorts by ACUITY, not arrival order.
- Continuous re-triage is mandatory; patient status can deteriorate while waiting.
- In routine ED: full resuscitation for non-breathing patient after airway opening.
- In disaster START triage: non-breathing after airway opening = BLACK tag (expectant care).
- ESI (Emergency Severity Index) = 5-level scale; further stratifies highest acuity.
- Nurse re-assesses every patient at intervals to catch deterioration early.
- Triage decision must account for available resources and likelihood of benefit.
Key definitions
Triage
Example
ED nurse assigns priority 1 to patient with airway obstruction, priority 2 to moderate abdominal pain, priority 3 to minor sprain.
Process of prioritizing patients by severity/urgency of condition; answers: 'Who cannot wait?'
Emergent (Priority 1)
Example
Airway obstruction, cardiac arrest, severe hemorrhage, chest pain (MI), unresponsive/seizing, severe trauma.
Immediate threat to life or limb; care needed NOW.
Urgent (Priority 2)
Example
Moderate abdominal pain, closed fracture with intact circulation, high fever, sutures-requiring laceration.
Serious but not immediately life-threatening; care needed within 30–60 minutes.
Non-Urgent (Priority 3)
Example
Minor sprains, chronic complaints, mild URI, prescription refills.
Stable condition that can safely wait.
START Triage (Disaster/Mass Casualty)
Example
RED = immediate/salvageable, YELLOW = delayed/serious, GREEN = minor/walking wounded, BLACK = expectant/deceased.
Simple Triage And Rapid Treatment; color-coded tags for field sorting.
Diagrams to know
- Three-tier ED triage pyramid (emergent > urgent > non-urgent)
- START triage color-coding flowchart (breathing? → mental status? → perfusion?)
PRIMARY SURVEY: ABCDE Framework
Important facts
- ABCDE is absolute hierarchy: never advance to next letter until current threat is managed.
- When two problems compete, treat the one HIGHER in ABCDE first.
- Jaw-thrust (not head-tilt/chin-lift) is the airway maneuver for suspected cervical spine injury.
- Oropharyngeal or nasopharyngeal airway insertion prepares for definitive airway (intubation/cricothyrotomy).
- Tension pneumothorax: needle decompression 2nd ICS midclavicular line (B-level emergency).
- Open chest wounds: apply occlusive dressing taped on 3 sides (allows air escape, prevents tension pneumothorax).
- Two large-bore peripheral IVs (16–18 gauge) provide rapid access for volume and drugs.
- AVPU faster than full GCS in initial assessment; check blood glucose in ALL altered mental status.
- Pupil abnormalities: unilateral dilation → herniation risk; both dilated/fixed → severe brainstem injury.
- Lethal triad in trauma: hypothermia + acidosis + coagulopathy = poor prognosis; prevent hypothermia aggressively.
- Secondary survey does NOT begin until primary survey threats are controlled.
Key definitions
Primary Survey
Example
Unresponsive patient: check airway patency (A) → attach O₂ and assess breathing (B) → establish IV, assess perfusion (C) → check pupils and glucose (D) → expose to find hidden injury, prevent hypothermia (E).
Rapid, systematic assessment to detect and treat immediately life-threatening conditions; follows ABCDE sequence without skipping steps.
Airway (A) with C-spine protection
Example
Stridor, gurgling, inability to speak, or foreign body = airway emergency. Use jaw-thrust + cervical collar in trauma.
Assess patency; open airway with head-tilt/chin-lift (or jaw-thrust if cervical spine injury suspected); remove obstruction; secure definitive airway if needed.
Breathing (B)
Example
Absent breath sounds unilaterally + hypotension + JVD = tension pneumothorax; needle decompression at 2nd ICS, midclavicular line.
Assess ventilation and oxygenation: rate, depth, symmetry, breath sounds, SaO₂; deliver O₂; support with BVM if inadequate.
Circulation (C) with hemorrhage control
Example
Tachycardia + hypotension + cool clammy skin + delayed cap refill = shock. Start massive transfusion protocol if indicated.
Assess pulse, BP, skin perfusion, capillary refill; control external bleeding with direct pressure; establish two large-bore IVs (16–18 gauge); begin fluid resuscitation.
Disability (D) — Neurologic status
Example
Altered mental status in trauma + tachycardia → check glucose (hypoglycemia is reversible); if normal, assess for head injury.
Quick neuro check: AVPU (Alert, Voice, Pain, Unresponsive) or Glasgow Coma Scale; pupil size/reactivity; blood glucose.
Exposure/Environment (E)
Example
Trauma patient with lethal triad risk: keep patient warm, avoid cold IV fluids, monitor temperature actively.
Fully expose patient to find hidden injuries; prevent hypothermia with warm blankets and warmed fluids; maintain core temperature.
Diagrams to know
- ABCDE decision tree (each letter with immediate interventions)
- Airway maneuver selection flowchart (head-tilt/chin-lift vs jaw-thrust)
- Tension pneumothorax signs & needle decompression anatomy
SECONDARY SURVEY & History
Important facts
- Pain assessment is part of secondary survey but NEVER overrides unaddressed ABC problems.
- Reassess immediately if ANY deterioration detected; return to primary survey if needed.
- All body regions must be inspected and palpated: head, neck, chest, abdomen, pelvis, extremities, back (log-roll).
- Full vital signs obtained in secondary survey; compare to baseline if available.
- Documentation must be clear, concise, and time-stamped for legal/handover purposes.
- SBAR prevents critical information loss; used in all critical-care transitions (ED to ICU, shift change, etc.).
Key definitions
Secondary Survey
Example
Patient stable after ABCs: inspect/palpate all body regions, obtain SAMPLE history, order indicated labs/imaging, reassess for deterioration.
Head-to-toe examination + focused history; performed AFTER primary survey threats are controlled; includes full vitals, diagnostics, and continuous reassessment.
SAMPLE History Mnemonic
Example
Patient with chest pain: SAMPLE reveals aspirin allergy, on lisinopril for HTN, ate 2 hrs ago, sharp pain started with deep breath.
S=Signs/symptoms, A=Allergies, M=Medications, P=Past medical history, L=Last oral intake, E=Events leading to presentation.
SBAR Handover
Example
To receiving ICU nurse: 'Situation: 45-year-old male with STEMI. Background: HTN, DM2. Assessment: Hemodynamically stable, troponin elevated. Recommendation: Monitor for dysrhythmia.'
S=Situation, B=Background, A=Assessment, R=Recommendation; structured communication to prevent information loss during transitions.
Diagrams to know
- SAMPLE history checklist (6 elements with examples)
- SBAR communication framework
HEMODYNAMIC MONITORING: Parameters & Targets
Formulas
MAP = DBP + (SBP − DBP) ÷ 3
Meaning
MAP = Mean Arterial Pressure, DBP = Diastolic BP, SBP = Systolic BP; calculated as diastolic + one-third of pulse pressure.
Watch out
Do NOT use (SBP + DBP) ÷ 2; that is WRONG. The formula weights diastole twice because it lasts twice as long. Also: trends matter more than single values.
When to use
Every time you need to assess perfusion adequacy; MAP ≥65 mmHg required for vital organ perfusion.
Common values
Value
≥65 mmHg
Symbol
MAP
Quantity
Mean Arterial Pressure minimum
Value
2–6 mmHg
Symbol
CVP
Quantity
Central Venous Pressure (normal)
Value
3–8 cmH₂O
Symbol
CVP
Quantity
CVP in cmH₂O
Value
≥0.5 mL/kg/hr
Symbol
UOP
Quantity
Urine output (adequate perfusion)
Value
90–120 mmHg
Symbol
SBP
Quantity
Systolic Blood Pressure (normal)
Important facts
- MAP ≥65 mmHg is the MINIMUM perfusion threshold for vital organs; 70–100 mmHg is typical target.
- Trends and clinical correlation matter MORE than single numbers; warm skin + good urine output confirms MAP is adequate.
- Urine output ≥0.5 mL/kg/hr = adequate renal perfusion (check every 1 hour in unstable patient).
- A-line insertion sites must be monitored for bleeding; distal limb checked for signs of impaired perfusion (pale, cool, weak pulse).
- CVP useful for guiding fluid resuscitation, but SVP (static venous pressure) alone does not reliably predict fluid responsiveness.
- Swan-Ganz: balloon must be inflated ONLY to obtain wedge reading, then deflated immediately (risk of PA rupture or infarction with prolonged inflation).
- Transducer must be re-zeroed and re-leveled after patient repositioning or after setup change.
- Watch for damped/flat waveforms (catheter clot, kink, or malposition); troubleshoot immediately.
Key definitions
Arterial Line (A-line)
Example
Transducer too high → falsely LOW reading; transducer too low → falsely HIGH reading. Re-level after patient repositioning.
Continuous, beat-to-beat blood pressure measurement + easy arterial sampling; transducer leveled at phlebostatic axis (4th ICS, midaxillary line) and zeroed to atmosphere.
Central Venous Pressure (CVP)
Example
CVP ↓ = hypovolemia (give fluids); CVP ↑ = fluid overload or RV failure (diuretics, afterload reduction).
Reflects right-heart filling and intravascular volume status; normal ≈ 2–6 mmHg (3–8 cmH₂O).
Pulmonary Artery (Swan-Ganz) Catheter
Example
PAWP ↑ = pulmonary edema risk; PAWP ↓ = hypovolemia. Never leave balloon inflated >2 min to prevent PA rupture.
Measures PA pressures, cardiac output, PAWP (pulmonary artery wedge pressure = estimate of left-heart filling); use declining but still examinable.
Phlebostatic Axis
Example
Place transducer stopcock at this anatomic level; error here causes false pressure readings.
Reference point for leveling hemodynamic transducers: 4th intercostal space at the midaxillary line (level of right atrium).
Diagrams to know
- Transducer leveling anatomic reference (phlebostatic axis location)
- Normal hemodynamic waveforms (arterial, CVP, PA, wedge)
- Hemodynamic parameter interpretation flow (high vs low CVP/MAP → next step)
ICU Environment: Priorities & Nursing Interventions
Common values
Value
30–45 degrees
Symbol
HOB
Quantity
Head-of-bed angle (VAP prevention)
Value
1:1 or 1:2
Symbol
Staffing
Quantity
Nurse-to-patient ratio in ICU
Important facts
- Prevention of iatrogenic harm is a core ICU nursing priority.
- HOB 30–45 degrees reduces aspiration risk and VAP incidence.
- Daily sedation interruption ('sedation holiday') allows assessment of readiness to wean from ventilator.
- Spontaneous breathing trial (SBT) daily: PS/CPAP mode, low support, assess if patient can breathe spontaneously (RR <35, SpO₂ ≥90%, no distress).
- Hand hygiene + sterile technique + aseptic handling are NON-NEGOTIABLE for line care.
- Early mobilization (even passive ROM or dangling at bedside) reduces delirium, VAP, VTE, and pressure injuries.
- Assess line necessity daily: if no longer needed, remove it immediately (reduces CLBSI risk).
- Stress-ulcer prophylaxis indicated for mechanically ventilated patients and those with coagulopathy or major trauma.
- Family involvement: explain alarms, set realistic expectations, support decision-making aligned with advance directives.
- Continuous reassessment and titration of support based on patient response, not just numbers.
Key definitions
Intensive Care Unit (ICU)
Example
Patient on mechanical ventilator + vasopressors + CRRT (continuous renal replacement therapy) requires ICU-level care.
High-acuity environment with continuous monitoring, high nurse-to-patient ratio (1:1 or 1:2), and advanced life support capacity (mechanical ventilation, vasoactive drugs, renal replacement therapy).
Ventilator-Associated Pneumonia (VAP) Prevention
Example
ICU nurse elevates HOB, prepares patient for SBT after sedation pause, checks readiness criteria (PaO₂/FiO₂, PEEP, RR <35).
Bundle: HOB ≥30–45 degrees, daily sedation interruption, spontaneous breathing trial daily, oral hygiene with chlorhexidine.
Central-Line Bloodstream Infection (CLBSI) Prevention
Example
Nurse checks CVP line daily: still needed? Site clean? No signs of infection? If not needed, advocate for removal.
Bundle: sterile technique on insertion, skin antisepsis (chlorhexidine), daily assessment for line necessity, prompt removal when no longer needed.
Venous Thromboembolism (VTE) & Pressure Injury Prevention
Example
Post-op patient in ICU: apply SCD immediately, start prophylactic heparin (unless contraindicated), reposition q2h, assess skin.
Early mobilization, sequential compression devices (SCD), pharmacologic prophylaxis (if not contraindicated), frequent repositioning, skin integrity assessment.
Stress-Ulcer Prophylaxis
Example
Intubated patient: PPI 40 mg daily or BID to prevent GI bleeding from stress ulcers.
Administer H₂-blockers or proton-pump inhibitors (PPI) to high-risk patients (mechanical ventilation >48 hrs, coagulopathy, major trauma/surgery).
Diagrams to know
- VAP bundle checklist (HOB angle, sedation interruption, SBT, oral hygiene)
- CLBSI prevention daily assessment flowchart
- VTE prophylaxis algorithm (risk stratification → SCD ± pharmacologic)
CRITICAL PRIORITY HIERARCHY & Nursing Management
Important facts
- Airway is ALWAYS the first priority in any emergency; a patient without an airway cannot survive.
- When two ABC problems coexist, the higher-priority letter wins (e.g., airway obstruction always before respiratory distress).
- Documentation must include time, intervention, patient response, and reasoning for decisions (critical for legal/continuity).
- Handover using SBAR prevents critical information loss during transitions and ensures safe continuity of care.
- Anticipate complications: airway loss → hypoxic brain injury, missed tension pneumothorax → cardiac arrest, uncontrolled hemorrhage → irreversible shock.
- Iatrogenic complications (device infections, ventilator injury, pressure injuries) are largely PREVENTABLE and are core nursing accountability.
- Patient & family education: brief, concrete, repeated; orient to what is happening and why each intervention is needed.
- Before ED discharge: provide clear return precautions (specific warning signs that warrant immediate return).
- RA 9173 (Philippine Nursing Practice Law): Nurses are accountable for safe, timely, quality care aligned with professional standards.
- NCM levels in Philippines: Level 1 (RN in critical care) and above require advanced assessment and intervention skills.
Key definitions
Priority Hierarchy in Emergency/Critical Care
Example
Patient with airway obstruction AND hemorrhage: secure airway FIRST, then control bleeding. Patient with respiratory distress AND hypotension: support breathing FIRST, then restore BP.
ABCDE is absolute: Airway ALWAYS before breathing, breathing before circulation, circulation before disability. When two problems compete, treat the one HIGHER in ABCDE first.
Stabilize Before Diagnosing
Example
Chest pain patient: O₂, IV, cardiac monitor, 12-lead EKG, troponin sent, but initial treatment (aspirin, nitroglycerin) does NOT wait for lab results.
Support airway, deliver oxygen, restore circulating volume BEFORE pursuing definitive diagnosis; investigation does not delay resuscitation.
Establish Access Early
Example
Trauma with tachycardia + weak pulse: two 18-gauge IVs placed immediately, fluids wide open, blood type ordered.
Two large-bore peripheral IVs (16–18 gauge) provide rapid pathway for fluids and drugs in any unstable patient.
Reassess After Every Intervention
Example
After IV fluid bolus: recheck BP, cap refill, skin perfusion. If still hypotensive → increase rate, consider vasopressor, search for occult bleeding.
Effectiveness judged by patient response, not task completion; if no improvement or deterioration, modify approach immediately.
Continuous Monitoring
Example
ED patient with syncope: attach monitor immediately, oxygen available, IV ready, watch for dysrhythmia.
Any unstable patient = cardiac monitor + pulse oximetry + frequent (or continuous) BP measurement.
Diagrams to know
- ABCDE priority sequence with competing scenarios
- Nursing management decision tree (stabilize → monitor → assess response → modify or escalate)
- When-to-escalate or call physician/team lead flowchart
High-Yield NLE Points (Exam Focused)
Important facts
- TRIAGE: Sorts by ACUITY (not arrival); Emergent = immediate, Urgent = 30–60 min, Non-urgent = can wait.
- DISASTER TRIAGE: Non-breathing after airway opening = BLACK tag (expectant); in routine ED = full resuscitation.
- ABCDE: Airway (with C-spine) → Breathing → Circulation (with hemorrhage control) → Disability → Exposure. DO NOT skip steps.
- AIRWAY MANEUVER: Jaw-thrust (not head-tilt/chin-lift) when C-spine injury suspected.
- TENSION PNEUMOTHORAX: Absent breath sounds + hypotension + JVD = needle decompression 2nd ICS midclavicular line (B-priority emergency).
- OPEN CHEST WOUND: Occlusive dressing taped on 3 sides (allows air escape).
- AVPU: Alert, Voice, Pain, Unresponsive; ALWAYS check blood glucose in altered mental status (reversible cause).
- HEMORRHAGE CONTROL: Direct pressure + two large-bore IVs (16–18 gauge) + fluid resuscitation.
- TRANSDUCER LEVELING: Phlebostatic axis = 4th ICS, midaxillary line; too high = falsely LOW BP, too low = falsely HIGH BP.
- CVP NORMAL: 2–6 mmHg; LOW = hypovolemia, HIGH = fluid overload/RV failure.
- MAP TARGET: ≥65 mmHg minimum; 70–100 typical; correlate with clinical signs (warm skin, urine output ≥0.5 mL/kg/hr).
- SWAN-GANZ: Never leave balloon inflated >2 min (risk of PA rupture).
- VAP PREVENTION: HOB ≥30–45°, daily sedation interruption, SBT daily, oral hygiene with chlorhexidine.
- CLBSI PREVENTION: Sterile technique + daily necessity assessment + prompt removal if not needed.
- LETHAL TRIAD (TRAUMA): Hypothermia + acidosis + coagulopathy = poor prognosis; prevent hypothermia aggressively.
- SECONDARY SURVEY: Head-to-toe exam + SAMPLE history; ONLY after ABC threats controlled; pain assessment does NOT override ABC.
- SBAR HANDOVER: Situation → Background → Assessment → Recommendation; prevents information loss.
- REASSESS AFTER EVERY INTERVENTION: Adjust based on patient response, not task completion.
- NURSING ACCOUNTABILITY (RA 9173): Safe, timely, quality care aligned with professional standards and scope of practice.
Must remember
- AIRWAY IS ALWAYS FIRST: Never advance ABCDE until current threat is managed. When two problems compete, treat the one HIGHER in the sequence.
- TRIAGE = ACUITY, NOT ARRIVAL: Emergent (immediate life/limb threat) seen first, regardless of arrival order. Continuous re-triage is mandatory.
- JAW-THRUST (not head-tilt/chin-lift) for C-spine injury suspects; head-tilt/chin-lift for no spinal concern.
- TENSION PNEUMOTHORAX SIGNS: Absent breath sounds + hypotension + JVD = needle decompression 2nd ICS midclavicular line (B-priority emergency).
- TRANSDUCER LEVELING: Phlebostatic axis = 4th ICS, midaxillary line. Too high = FALSE LOW reading; too low = FALSE HIGH reading.
- CVP INTERPRETATION: 2–6 mmHg normal; LOW = hypovolemia (give fluids); HIGH = fluid overload/RV failure (diuretics/afterload reduction).
- MAP ≥65 mmHg MINIMUM for organ perfusion; correlate with clinical signs (warm skin, UOP ≥0.5 mL/kg/hr, clear mentation).
- SECONDARY SURVEY starts ONLY AFTER ABC threats are controlled; pain assessment is part of secondary survey, NOT a primary priority.
- VAP PREVENTION BUNDLE: HOB 30–45°, daily sedation interruption, daily SBT, oral hygiene — all are MUST-DOS in ventilated patients.
- RA 9173 (PH Nursing Law): Nurses are accountable for safe, timely, quality care aligned with professional standards; NCM Levels define scope of practice.
Last minute tips
- EXAM QUESTION TIP: 'Patient without airway' always = manage A first, even if bleeding is visible. Airway > Breathing > Circulation > Disability.
- DISASTER TRIAGE FLIP: In routine ED, resuscitate non-breathing patient after airway opening. In disaster START triage, that same patient = BLACK tag (expectant care). Know which context the question is asking about.
- TRANSDUCER ERRORS: If BP reading seems wrong, check (1) transducer at phlebostatic axis? (2) Zeroed to atmosphere? (3) No kinks/bubbles in tubing? Most errors are setup mistakes, not patient problems.
- PRIORITY HIERARCHY TRAP: Questions ask 'what do you do first?' when patient has multiple problems. ALWAYS apply ABCDE order, not severity rank. Airway obstruction beats massive bleeding (A before C).
- HEMODYNAMIC TARGETS: Know MAP ≥65 mmHg, CVP 2–6 mmHg, UOP ≥0.5 mL/kg/hr, and that TRENDS matter more than single values. A dropping MAP with cool skin is more concerning than a high CVP with good perfusion.
Comparison tables
Triage Categories in ED vs. Disaster (START Triage)
| Triage Level | ED Priority | Timely Care Window | Disaster Tag | Care Approach | |
|---|---|---|---|---|---|
| Highest Acuity | Emergent (P1) | Immediate | NOW | RED | Full resuscitation (routine); expectant if non-breathing after airway opening (disaster) |
| Moderate Acuity | Urgent (P2) | Serious but not life-threatening | 30–60 min | YELLOW | Definitive care delayed; stabilize and monitor |
| Low Acuity | Non-Urgent (P3) | Stable/minor | Can wait | GREEN | Minor interventions; discharge with precautions |
| Deceased/Unrecoverable | N/A | N/A | N/A | BLACK | Comfort care only; routine ED = full resuscitation |
ABCDE Primary Survey: Elements & Key Interventions
| Element | Assessment Focus | Immediate Action | Red Flag Signs | Next Intervention If Problem |
|---|---|---|---|---|
| A — Airway (+ C-spine) | Patency, obstruction, ability to speak | Open airway (head-tilt/chin-lift or jaw-thrust); remove obstruction; suction; oropharyngeal airway | Stridor, gurgling, speech loss, foreign body, edema, blood | Prepare for intubation or cricothyrotomy; immobilize C-spine |
| B — Breathing | Rate, depth, symmetry, breath sounds, SaO₂ | Oxygen delivery; BVM if inadequate; position for easy breathing | Absent breath sounds, RR <8 or >30, SpO₂ <90%, stridor, accessory muscle use | Support ventilation; needle decompression if tension PTX; intubation if needed |
| C — Circulation (+ hemorrhage) | Pulse (rate, quality), BP, skin color/temp, cap refill | Direct pressure on bleeding; two large-bore IVs; fluid resuscitation; assess for shock | Tachycardia, hypotension, cool clammy skin, delayed cap refill, pale/cyanotic | Increase fluid rate; consider vasopressor; massive transfusion protocol if indicated |
| D — Disability (neuro) | AVPU or GCS, pupils, blood glucose | Quick neuro check; assess glucose; protect spine | Unresponsive, abnormal pupils, fixed/dilated pupils, hypoglycemia | Check glucose (give D50 if hypoglycemic); assess for head/spinal injury; prepare for escalation |
| E — Exposure/Environment | Hidden injuries, core temperature | Fully expose; prevent hypothermia; apply warm blankets and warmed fluids | Hypothermia, obvious trauma/wounds not yet detected | Active rewarming; warm all fluids; continuous temperature monitoring |
Hemodynamic Parameter Interpretation: What High/Low Means
| Parameter | Normal Value | When HIGH | When LOW | Likely Cause (HIGH) | Likely Cause (LOW) |
|---|---|---|---|---|---|
| MAP | 70–100 mmHg | >100 mmHg | <65 mmHg | Hypertension, sepsis, sympathetic overload | Hypovolemia, septic shock, cardiogenic shock, vasodilation |
| CVP | 2–6 mmHg | >6 mmHg | <2 mmHg | Fluid overload, RV failure, pulmonary HTN, pericardial effusion | Hypovolemia, dehydration, excessive diuresis |
| Urine Output | ≥0.5 mL/kg/hr | >0.5 mL/kg/hr | <0.5 mL/kg/hr | Fluid overload, diuretic use, hypoglycemia | Hypovolemia, acute kidney injury, sepsis, cardiogenic shock |
| Skin Perfusion | Warm, dry, normal cap refill <2 sec | N/A | Cool, clammy, delayed cap refill | N/A | Shock (any type); inadequate MAP or cardiac output |
Common ICU Complications: Prevention vs. Recognition
| Complication | Prevention Bundle | Early Signs/Recognition | Nursing Intervention | High-Risk Patients |
|---|---|---|---|---|
| VAP (Ventilator-Assoc. Pneumonia) | HOB 30–45°, daily sedation interruption, SBT daily, oral hygiene qid | Fever, new infiltrate on CXR, purulent sputum, increased WBC | Check HOB angle, assess SBT readiness, provide oral care, monitor temp/WBC | Patients on mechanical ventilation >48 hrs |
| CLBSI (Central-Line Infection) | Sterile insertion, aseptic handling, daily necessity check, prompt removal | Fever, elevated WBC, positive blood culture, erythema/drainage at site | Daily site assessment, monitor temp/WBC, review line necessity, maintain asepsis | Long-term CVP/PICC, immunocompromised, sepsis risk |
| VTE (Clot/PE) | SCD, prophylactic anticoagulation (if not contraindicated), early mobilization | Unilateral leg swelling, calf pain, sudden dyspnea, chest pain, desaturation | Apply SCD immediately post-op, assess for calf tenderness, maintain DVT prophylaxis, early ambulation | Immobilized, post-op, trauma, malignancy, hypercoagulable state |
| Pressure Injury (Decubitus) | Frequent repositioning q2h, proper padding, skin assessment q4h, early mobilization | Erythema, blanching hyperemia, non-blanching erythema, tissue breakdown | Reposition q2h, assess skin daily, use pressure-relief devices (mattress, pillows) | Immobilized, sedated, poor nutrition, incontinence, elderly |
| GI Bleed (Stress Ulcer) | H₂-blocker or PPI for high-risk patients (ventilated >48 hrs, trauma, coagulopathy) | Hematemesis, melena, tarry stools, falling Hgb, positive fecal occult blood | Admin prophylactic PPI/H₂-blocker, monitor Hgb/Hct, assess stool, NGT lavage if bleeding | Mechanically ventilated, major surgery/trauma, coagulopathy, renal failure |
Diagrams
Principles of Emergency & Critical Care: Complete Concept Map
Master overview showing how triage, primary survey, hemodynamics, and ICU priorities interconnect. Use this to see the big picture before drilling into details.
Primary Survey ABCDE Decision Tree with Red Flags
Step-by-step flowchart guiding you through the primary survey. Each box shows assessment, red flag signs, and the intervention needed before advancing to the next letter.
Shock States & Hemodynamic Response Cascade
Shows the progression of shock states (hypovolemic, distributive/septic, cardiogenic) and how hemodynamic parameters (MAP, CVP, HR, UOP) change. Use to predict what happens next and guide interventions.
Hemodynamic Transducer Setup & Troubleshooting
Critical troubleshooting flow for arterial line and CVP readings. Shows setup steps, common errors, and how to recognize/fix falsely high or low readings.
ICU Complication Prevention: Daily Safety Checklist Bundle
Daily nursing checklist for preventing four major ICU complications: VAP, CLBSI, VTE, and pressure injury. Use each shift to ensure prevention bundles are in place.