NLE Emergency & Critical Care Nursing — Principles of Emergency & Critical Care NursingRevision Notes

Exam Tips

• NLE questions often present a list of patients and ask who is seen first — always pick the one with the most immediate threat to airway, breathing, or circulation.
• Disaster/mass-casualty scenario questions: if the patient is not breathing even after airway is opened, answer is BLACK tag.
• Memorize the three tiers and their time frames: Emergent = immediate, Urgent = 30–60 minutes, Non-Urgent = can wait.
• A seizing patient is always Priority 1 (Emergent) — do not be distracted by other patients with less serious presentations.

Key Points

• Triage prioritizes patients by SEVERITY and URGENCY — not by who arrived first.
• The classic three-tier ED triage system: Emergent (Priority 1), Urgent (Priority 2), Non-Urgent (Priority 3).
• Emergent (Priority 1): Immediate life or limb threat — airway obstruction, cardiac arrest, active hemorrhage, respiratory distress, unresponsive/seizing patient, severe trauma. Seen at once.
• Urgent (Priority 2): Serious but not immediately life-threatening — care within 30 to 60 minutes. Examples: moderate abdominal pain, closed fracture with intact circulation, high fever, laceration needing sutures.
• Non-Urgent (Priority 3): Stable conditions that can safely wait — minor sprains, mild URI symptoms, prescription refills.
• Many hospitals now use a five-level scale such as the Emergency Severity Index (ESI) for finer stratification.
• CONTINUOUS RE-TRIAGE is mandatory — a patient's condition can deteriorate while waiting.
• START Triage (mass-casualty/disaster): Red = Immediate (salvageable life threat), Yellow = Delayed (serious but can wait), Green = Minor (walking wounded), Black = Expectant/Deceased.
• KEY INVERSION in disaster triage: A non-breathing patient who does NOT breathe even after airway opening is tagged BLACK in START — the opposite of routine ED care where full resuscitation is done.
• Disaster triage follows the principle of the GREATEST GOOD for the GREATEST NUMBER.

Definitions

Section Title

Triage: Sorting by Acuity, Not Arrival

Common Mistakes

• Confusing routine ED triage (resuscitate non-breathing patient) with START disaster triage (tag non-breathing patient BLACK after airway opening).
• Assuming that the first patient to arrive is seen first — triage is acuity-based, never arrival-based.
• Forgetting that re-triage is an active, continuous nursing responsibility — not done only once on arrival.
• Mixing up Priority 1 (Emergent) with Priority 2 (Urgent) — a closed fracture with intact circulation is Priority 2, not Priority 1.

Exam Tips

• Any NLE question listing multiple problems — treat them in ABCDE order. Airway problem wins over breathing, which wins over circulation.
• If a trauma patient needs airway opening — answer is jaw-thrust, not head-tilt/chin-lift.
• Altered mental status + unknown cause = always check blood glucose first (reversible cause).
• GCS ≤ 8 = consider definitive airway (intubation) — patient cannot protect their own airway.
• Lethal triad: remember Hypothermia + Acidosis + Coagulopathy. Preventing hypothermia is the nursing action in E of the primary survey.
• Two large-bore IVs (16–18 gauge) = priority access for any unstable emergency patient.

Key Points

• The primary survey rapidly detects and treats immediately life-threatening conditions in a fixed sequence: A-B-C-D-E.
• ABSOLUTE RULE: Do not advance to the next letter until the current threat is controlled.
• A — AIRWAY (with cervical spine protection): Check patency — can the patient speak? Listen for stridor or gurgling. Inspect for obstruction (tongue, secretions, blood, foreign body, edema). Interventions: head-tilt/chin-lift (no C-spine injury), jaw-thrust (suspected C-spine injury), suction, oropharyngeal airway (OPA) or nasopharyngeal airway (NPA), prepare for definitive airway.
• B — BREATHING: Assess rate, depth, symmetry, chest wall movement, breath sounds, and SpO2. Administer oxygen. Support ventilation with BVM if inadequate. Immediate threats: tension pneumothorax (needle decompression at 2nd ICS, midclavicular line), open chest wound (three-sided occlusive dressing).
• C — CIRCULATION (with hemorrhage control): Assess pulse rate/quality, BP, skin color/temperature, capillary refill. Control external bleeding with DIRECT PRESSURE. Establish two large-bore peripheral IVs (16–18 gauge). Begin fluid resuscitation. Signs of shock: tachycardia, hypotension, cool/clammy skin, delayed capillary refill (>2 seconds).
• D — DISABILITY (neurologic status): Rapid neuro check using GCS (Glasgow Coma Scale) or AVPU scale. Check PUPIL SIZE and REACTIVITY. Always check BLOOD GLUCOSE — hypoglycemia is a rapidly reversible cause of altered consciousness.
• E — EXPOSURE/ENVIRONMENT: Fully expose the patient to find ALL injuries (remove clothing). Then PREVENT HYPOTHERMIA with warm blankets and warmed IV fluids.
• LETHAL TRIAD in trauma: Hypothermia + Acidosis + Coagulopathy — all three worsen each other and dramatically increase mortality. Preventing hypothermia during Exposure is a key nursing action.
• AVPU Scale: A = Alert, V = responds to Voice, P = responds to Pain, U = Unresponsive.
• Jaw-thrust is the ONLY safe airway maneuver when cervical spine injury is suspected.
• Airway ALWAYS comes before Breathing, Breathing before Circulation — the ABCDE priority hierarchy is absolute.

Definitions

Section Title

The Primary Survey: ABCDE Framework

Common Mistakes

• Using head-tilt/chin-lift in a trauma patient with suspected cervical spine injury — always use jaw-thrust.
• Moving to Breathing (B) before fully addressing the Airway (A) — violates the absolute ABCDE rule.
• Forgetting to check blood glucose in a patient with altered mental status — hypoglycemia is reversible and must be ruled out.
• Skipping re-warming during Exposure — leaving the patient exposed without warm blankets contributes to the lethal triad.
• Confusing direct pressure for hemorrhage control (C) with tourniquet as first choice — direct pressure is the priority first intervention for external bleeding.
• Neglecting to establish two large-bore IV lines early — access is critical for fluid and drug administration.

Exam Tips

• If a question asks what the nurse does NEXT after completing the primary survey and stabilizing life threats — the answer is begin the secondary survey.
• SAMPLE: memorize in order — Signs/Symptoms, Allergies, Medications, Past History, Last Intake, Events.
• SBAR for handover is a patient safety competency — expect communication-based NLE scenarios.
• If during a secondary survey the patient deteriorates — return to primary survey (A → B → C → D → E), do not continue with the secondary survey.

Key Points

• The secondary survey begins ONLY after the primary survey is complete and life threats are controlled.
• It is a comprehensive head-to-toe physical examination combined with a focused history.
• The SAMPLE mnemonic structures the history: S = Signs and Symptoms, A = Allergies, M = Medications, P = Past Medical History, L = Last Oral Intake, E = Events leading to the presentation.
• Inspect and palpate EVERY body region systematically from head to toe.
• Obtain a FULL SET of vital signs during the secondary survey.
• Order indicated diagnostic tests (labs, imaging) based on findings.
• Pain is assessed during the secondary survey but NEVER takes priority over an unaddressed A, B, or C problem.
• CONTINUOUS REASSESSMENT: Any deterioration found during the secondary survey means RETURN IMMEDIATELY to the primary survey.
• SBAR is used for structured handover: Situation, Background, Assessment, Recommendation.

Definitions

Section Title

The Secondary Survey and SAMPLE History

Common Mistakes

• Starting the secondary survey before the primary survey is complete — a common distractor in NLE questions.
• Treating pain management as the first priority — comfort is important but never before airway, breathing, or circulation.
• Failing to reassess after each intervention — the secondary survey is dynamic, not a one-time task.
• Forgetting LAST ORAL INTAKE in SAMPLE — critical for aspiration risk and pre-procedural planning.

Exam Tips

• VAP prevention = Head of bed 30–45 degrees + daily sedation interruption + oral care — memorize this bundle.
• CLABSI prevention = aseptic technique + daily review of line necessity.
• ICU nurse-to-patient ratio = 1:1 or 1:2 — significantly higher than general wards (which may be 1:8 or more in Philippine settings).
• Expect NLE scenarios about which intervention prevents which ICU complication — match the bundle to the complication.

Key Points

• The ICU concentrates the sickest patients with continuous monitoring and advanced life support capabilities.
• Nurse-to-patient ratio in the ICU: typically 1:1 or 1:2 — much higher than general wards.
• ICU capabilities: mechanical ventilation, vasoactive infusions, renal replacement therapy, invasive hemodynamic monitoring.
• Prevention of iatrogenic (hospital-caused) harm is a CENTRAL nursing priority in the ICU.
• VAP Prevention (Ventilator-Associated Pneumonia): Elevate head of bed 30–45 degrees, daily sedation interruption (spontaneous awakening trials), oral care with chlorhexidine, subglottic suctioning.
• CLABSI Prevention (Central Line-Associated Bloodstream Infection): Strict aseptic technique during insertion and care, daily review of line necessity — remove lines as soon as no longer needed.
• VTE Prevention (Venous Thromboembolism): Early mobilization, sequential compression devices (SCDs), pharmacologic prophylaxis (low-molecular-weight heparin) where indicated.
• Pressure Injury Prevention: Frequent repositioning (every 2 hours), skin assessment, pressure-relieving surfaces.
• Stress Ulcer Prophylaxis: H2 blockers or proton pump inhibitors (PPIs) for high-risk ventilated patients.
• The nurse is the FAMILY'S ANCHOR — explaining alarms, equipment, and supporting decision-making in an overwhelming environment.
• Advance directives and patient wishes must be respected and communicated — consistent with Philippine law and ethical nursing practice under RA 9173.

Definitions

Section Title

The Critical Care Environment and ICU Nursing

Common Mistakes

• Forgetting to elevate the head of bed 30–45 degrees for all mechanically ventilated patients — the most common VAP prevention measure tested.
• Not performing daily review of central line necessity — lines that are no longer needed should be removed promptly.
• Overlooking the nurse's role as family communicator — especially in Philippine healthcare settings where families are highly involved.
• Thinking ICU nursing is only about technology — prevention bundles and compassionate family support are equally critical.

Formulas

Exam Tips

• MAP formula: Diastolic + 1/3 of Pulse Pressure. Minimum target MAP = 65 mmHg.
• Minimum urine output = 0.5 mL/kg/hr — calculate for the patient's weight in NLE computation questions.
• CVP normal = 2–6 mmHg. Low = hypovolemia. High = fluid overload or right heart failure.
• Transducer too HIGH → reads too LOW. Transducer too LOW → reads too HIGH. Think of it like a water level — the lower the reservoir, the higher the column of water.
• Phlebostatic axis = 4th ICS, midaxillary line — memorize this landmark.
• Swan-Ganz balloon: inflate only briefly for wedge reading — prolonged inflation = pulmonary artery rupture.

Key Points

• Hemodynamic monitoring measures pressures and flows in the cardiovascular system to guide fluid and drug therapy.
• ARTERIAL LINE: Provides continuous beat-to-beat blood pressure readings and easy arterial blood gas (ABG) sampling. Leveled at the PHLEBOSTATIC AXIS (4th intercostal space, midaxillary line). Must be ZEROED to atmospheric pressure before use.
• Transducer position affects readings: Too HIGH = falsely LOW readings. Too LOW = falsely HIGH readings.
• Monitor arterial line insertion site for bleeding and distal limb for signs of impaired perfusion (pallor, coolness, numbness).
• CENTRAL VENOUS PRESSURE (CVP): Reflects RIGHT-HEART FILLING and intravascular volume status. Normal: 2 to 6 mmHg (approximately 3 to 8 cmH2O). LOW CVP = hypovolemia. HIGH CVP = fluid overload or right heart failure.
• PULMONARY ARTERY (SWAN-GANZ) CATHETER: Measures pulmonary artery pressures, cardiac output, and pulmonary artery wedge pressure (PAWP) — which estimates LEFT-HEART filling pressure. NEVER inflate the balloon longer than needed for a wedge reading — risk of pulmonary artery rupture or infarction.
• MEAN ARTERIAL PRESSURE (MAP): The key perfusion number. Normal target = MAP ≥ 65 mmHg to perfuse vital organs.
• MAP formula: MAP = Diastolic BP + 1/3 (Pulse Pressure). Pulse Pressure = Systolic BP − Diastolic BP.
• Urine output is the clinical correlate of MAP: Target ≥ 0.5 mL/kg/hr confirms adequate renal perfusion.
• Warm skin + good urine output + clear mentation = signs that perfusion pressure is translating into actual tissue perfusion.
• Trends matter more than single values — always correlate numbers with the patient's clinical picture.

Definitions

Section Title

Hemodynamic Monitoring

Common Mistakes

• Confusing the effect of transducer height on readings — HIGH transducer gives FALSELY LOW reading; LOW transducer gives FALSELY HIGH reading.
• Forgetting to zero the arterial line transducer to atmospheric pressure before use.
• Inflating the Swan-Ganz catheter balloon for too long — should only be inflated briefly to get the wedge reading, never left inflated.
• Using blood pressure alone to assess perfusion — urine output, skin temperature, and mentation are equally important clinical correlates.
• Confusing CVP (right heart filling) with PAWP (left heart filling).

Exam Tips

• Any NLE question about priority nursing action in an emergency = follow ABCDE. The highest unsolved problem in the sequence is always the answer.
• Two large-bore IVs = 16–18 gauge — this number is tested.
• Reassess after every intervention — the NLE frequently tests whether you know that response to the intervention, not completion of the task, is the measure of success.
• SBAR is the standard structured communication tool — know its four components: Situation, Background, Assessment, Recommendation.
• Return precautions at ED discharge = patient education responsibility of the nurse, consistent with RA 9173 scope of nursing practice.

Key Points

• Priority hierarchy is ALWAYS ABCDE: Airway > Breathing > Circulation > Disability > Exposure. When two problems compete, the one higher in ABCDE wins.
• STABILIZE before diagnosing — support airway, deliver oxygen, restore volume before pursuing the definitive diagnosis.
• Establish IV access EARLY: Two large-bore peripheral IVs (16–18 gauge) for any unstable patient.
• Attach CONTINUOUS monitoring: cardiac monitor, pulse oximetry, frequent or continuous blood pressure.
• REASSESS after EVERY intervention — effectiveness is judged by the patient's response, not by task completion.
• Document and communicate using SBAR for structured, safe handover.
• Most dangerous complications from missed primary survey problems: airway loss → hypoxic brain injury; unrecognized tension pneumothorax → cardiac arrest; untreated hemorrhage → irreversible shock.
• Iatrogenic complications (infections, pressure injuries, ventilator-associated events) are largely PREVENTABLE and are a core nursing accountability.
• Patient and family teaching in the acute phase: brief, concrete, repeated. Orient the conscious patient to each intervention.
• Provide CLEAR RETURN PRECAUTIONS before ED discharge — specific warning signs that should prompt immediate return.
• Under RA 9173, the registered nurse is accountable for safe, competent, and ethical care — this includes both technical interventions and communication responsibilities.

Definitions

Section Title

Nursing Management, Priority Interventions, and Complications

Common Mistakes

• Pursuing the diagnostic workup before stabilizing the patient — always stabilize airway, breathing, and circulation first.
• Failing to reassess after each intervention — the nurse must evaluate the patient's response, not just confirm the task was done.
• Using small-gauge IVs (e.g., 22 gauge) for an unstable patient — 16–18 gauge allows rapid fluid and drug administration.
• Providing detailed, complex discharge teaching in the acute phase — keep it brief, simple, and concrete.
• Not using SBAR for handover — verbal informal report increases risk of missed critical information.