Nursing · Adult clinical nursing
Take the first look properly, in a fixed order, on somebody you know nothing about — then look again
In the exams: Saudi Nursing Licensure Examination: Critical and emergency care (Core); NMBA Outcomes-Based Assessment: Adult health and deterioration (Heavily represented)
Injury is among the leading causes of death in people under forty worldwide, most of those deaths occur in poorer countries, and a large proportion are preventable. For most of the world's population unscheduled care is the only care, which makes the emergency department the place where undiagnosed illness, injury, mental health crisis, poverty and violence all arrive — and nothing arrives sorted. Triage is a nursing act with life-and-death consequences performed in minutes on incomplete information, and it is the highest-leverage skill in the department. In bleeding, sepsis, stroke, heart attack and poisoning, damage accumulates by the minute. And most of what arrives is not dramatic: it is people who are frightened, in pain, old, alone, or unable to get care anywhere else, and treating that as a misuse of the service rather than as the service's actual work is the commonest error in this subject.
Injury is among the leading causes of death in people under forty worldwide, and road traffic injury alone accounts for an enormous share. Most of those deaths occur in poorer countries and a large proportion are preventable.
For most of the world's population, unscheduled care is the only care, and the emergency department is where undiagnosed illness, injury, mental health crisis, poverty and violence all arrive. Nothing arrives sorted.
Triage is a nursing act with life-and-death consequences, performed in minutes with incomplete information. Getting it right is the single highest-leverage skill in the department.
In bleeding, sepsis, stroke, heart attack and poisoning, damage accumulates by the minute and what happens in the first hour determines what is recoverable. Speed is not the same as haste.
The department is largely full of people who are frightened, in pain, old, alone, or unable to access care elsewhere. Treating that as a misuse of the service rather than as the service's actual work is the commonest error in attitude.
Triage ranks patients by how quickly they will come to harm if not seen, not by how ill they appear or how loudly they present. Those are different things and conflating them kills people.
Triage asks whether this person can safely wait, and for how long. Attempting a diagnosis at triage slows the queue and produces worse decisions than a rapid structured look.
Airway, breathing, circulation, conscious level, pain, and the observations. A respiratory rate counted at triage has changed more outcomes than any other single number taken there.
A silent child, a withdrawn older person, somebody who has stopped complaining, and a patient nobody has looked at for an hour. Noisy patients get attention; deteriorating ones frequently go quiet.
A category assigned on arrival describes that moment, and people deteriorate in waiting rooms. Systematic reassessment of those who are waiting is the mechanism that catches it, and it is the first thing lost when the department is full.
Airway, breathing, circulation, disability, exposure. The order reflects how quickly each kills, and following it means that nothing lethal is missed while something interesting is examined.
Problems are corrected as they are found rather than catalogued for later, so an obstructed airway is opened before breathing is assessed. That discipline is what makes the sequence useful rather than ceremonial.
The survey is done again after every intervention and whenever the patient changes, because a patient who was stable five minutes ago may not be. A single assessment on arrival is a snapshot of a moving thing.
In a resuscitation, allocated roles — airway, circulation, drugs, documentation, team leader — prevent the situation where four people do the same thing and nobody does the rest. Saying roles out loud takes seconds.
Observations and findings spoken aloud, and written as they happen, is how a team stays aligned. Reconstructed afterwards from memory, the timeline is unreliable in exactly the cases where it matters.
Facial injury, bleeding into the mouth, swelling, burns to the airway, a reduced conscious level and vomiting all threaten the airway in an injured patient. Several can worsen over minutes.
In suspected spinal injury the airway is still the priority and is opened with manual control of the neck rather than left obstructed. An airway sacrificed to spinal caution kills the patient it protected.
Hoarseness, stridor, soot in the mouth or nose, singed facial hair, burns around the face, a swelling neck, or a patient who cannot lie flat. These predict obstruction before it happens, and that is when help is called.
An injured, painful, frightened patient with a full stomach vomits, and suction that is present, assembled and tested is what prevents aspiration. Discovering the suction does not work at that moment is a recognised disaster.
Impressive injuries elsewhere draw attention away from the airway, and a patient with a deformed limb and a compromised airway is an airway problem. That reordering is the discipline the sequence exists to enforce.
Chest movement, air entry on each side, the rate and effort of breathing, the position of the windpipe, and whether the chest is bruised, sucking or crackling under the skin. Comparing the two sides finds most of it.
Air accumulating in the chest under pressure collapses the lung and pushes on the heart, causing severe breathlessness, absent air entry on one side, and a falling blood pressure. It kills quickly and is relieved immediately.
Substantial blood in the chest cavity causes breathlessness and shock together, and the blood loss is frequently larger than expected because a chest holds litres. It is both a breathing and a circulation problem.
Multiple rib fractures cause severe pain that prevents breathing deeply, which causes lung collapse and pneumonia. Pain relief in rib fractures is respiratory treatment, and it is consistently under-provided in older patients.
An open chest wound that draws air in with each breath needs covering in a way that allows air out but not in. Sealing it completely can create the trapped-air emergency described above.
Direct pressure, elevation, packing and where necessary a tourniquet stops external bleeding, and no amount of fluid replaces control of the source. The most effective intervention is usually somebody's hands.
The chest, the abdomen, the pelvis, around the thigh bones, and on the floor at the scene. A patient in shock with no visible bleeding is bleeding into one of those places, and asking which one directs everything.
A correctly applied tourniquet for catastrophic limb bleeding is life-saving, applied tight enough to stop the bleeding, timed, and not loosened to check. Reluctance to apply one has cost lives.
A rising pulse, cool peripheries, a narrowing gap between the pressures, restlessness, thirst and reduced urine output. Young patients maintain their blood pressure until they are severely depleted and then fall suddenly.
A bleeding patient who becomes cold clots poorly, which causes more bleeding and more cooling. Keeping a trauma patient warm is haemorrhage treatment, and it is regularly forgotten while the exciting interventions happen.
A rapid conscious level assessment, pupil size and reaction, limb movement and blood glucose. Every collapsed or confused patient has their glucose checked, because a treatable hypoglycaemia looks exactly like a stroke or a head injury.
A conscious level that is falling, however slowly, indicates rising pressure or worsening injury inside the skull and needs urgent action. A single low score matters less than a score that is dropping.
Significant trauma, particularly with head injury or unconsciousness, is managed with spinal precautions until assessment allows otherwise. Careless movement can turn a stable injury into permanent paralysis.
Log rolling maintains alignment and requires numbers and a leader, and corners cut because the department is busy is exactly where harm occurs. The person controlling the head gives the commands.
Low glucose, low oxygen, alcohol, drugs, infection, low sodium and pain all cause confusion in an injured patient. Assuming the head injury explains it means missing the thing that is actually treatable.
Injuries to the back, the perineum, the armpits, under dressings and inside clothing are missed because nobody exposed them. A full look is part of the assessment rather than an optional extra.
Exposure is done in stages, with warmth restored between, because a trauma patient cools fast and cold kills. Leaving somebody uncovered while the team discusses them is both harmful and humiliating.
People are undressed, examined and catheterised in front of strangers, sometimes while fully aware. Curtains, a covering sheet, explaining before touching and removing anybody not needed are achievable in every department.
Cut clothing, rings removed before swelling, possessions documented and kept safe. Lost belongings are a genuine and common grievance, and for some patients that ring was everything they owned.
Who may see or touch a person, what may be removed and who should be present matters enormously to some patients, and asking rather than assuming rarely delays anything by more than seconds.
Once the immediate threats are controlled, a systematic examination from scalp to toes, including the back, finds the injuries the first survey deliberately ignored. Missed injuries are found here or not at all.
What happened, how fast, from what height, was there a helmet or belt, was anybody else hurt, how much do they remember. Mechanism predicts injuries that are not yet apparent.
Blood thinners, steroids, diabetes treatment, heart failure, dementia, pacemakers and allergies all change what will happen. This is where a second person can be useful while the first works.
Findings change — a soft abdomen becomes tender, a numb hand is discovered, swelling closes an airway. Repeating the examination is how the evolving injury is caught.
Recording that the back was examined, the pulses were present and the abdomen was soft is what allows a later change to be recognised as new. Absent documentation is indistinguishable from an absent examination.
The great majority of head injuries do well, and the task is identifying the few with bleeding inside the skull. That identification rests on specific features rather than on how bad the impact looked.
A falling conscious level, repeated vomiting, a seizure, a focal weakness, a suspected skull fracture, severe headache, anybody on blood thinners, and older people who have fallen. Any of these changes the urgency completely.
A person on anticoagulants who has hit their head can bleed inside the skull from an apparently trivial injury, and may do so hours later. They are not sent home on the basis of looking well.
Bleeding in older people can develop over days to weeks after a minor fall, presenting as confusion, drowsiness, headache or a change in walking. It is regularly diagnosed as dementia or a urinary infection.
Who should stay with them, what to watch for, what should bring them back immediately, and no alcohol or driving. Written down, because verbal head injury advice is given to somebody whose memory is the injured organ.
High-energy injury, a fall from height, a diving injury, injury with head trauma, or an unconscious patient is managed with spinal precautions. The assumption is cheap and the alternative is permanent.
Neck or back pain, tingling, numbness, weakness, a sense of electric shock, or an inability to feel their limbs. Those reports are taken at face value and documented exactly.
A high spinal injury can cause low blood pressure with a slow rather than fast pulse, which looks nothing like bleeding and leads to the wrong treatment if not recognised. The combination is the clue.
Prolonged immobilisation on a hard surface causes pressure damage within hours, impairs breathing and makes vomiting dangerous. Precautions are maintained properly and removed as soon as assessment permits.
Somebody who cannot feel or move is at immediate risk of pressure injury and urinary retention, and both are managed on arrival rather than once the acute phase passes.
Air under pressure in the chest, a large volume of blood in the chest, an open chest wound, and fluid compressing the heart. All four are identified in the first survey and all four are relieved rather than investigated.
Blood accumulating in the sac around the heart prevents it filling, producing shock with distended neck veins and quiet heart sounds. It is rare, rapidly fatal, and relieved by drainage.
A lung bruised by the impact deteriorates over hours, so a patient whose breathing was adequate on arrival can fail later. That is why chest injury patients are observed rather than discharged on an initial assessment.
Rib fractures in older patients carry a high rate of pneumonia and death, principally because pain prevents deep breathing. Aggressive pain relief, breathing exercises and early mobility are the treatment.
A wound to the chest may involve the lung, the heart, the great vessels or the abdomen depending on angle, and an apparently small entry wound says nothing about internal damage. Assumptions of minor injury here are dangerous.
The abdomen accommodates a great deal of blood with little external sign, so a shocked patient after blunt injury is assumed to be bleeding there until shown otherwise. Serial examination detects the developing abdomen.
A fractured pelvis can bleed litres into the pelvic space, and is associated with injury to the bladder, urethra and bowel. It is handled minimally and bound rather than repeatedly examined for movement.
Blood at the tip of the penis, bruising of the perineum or an inability to pass urine after pelvic injury suggests urethral injury, and catheterisation is not attempted. Doing so can convert a partial injury into a complete one.
A stab wound looks small and the track inside may be long, crossing the chest and abdomen. Nothing is inserted into the wound to explore it and the object, if still in place, is left alone.
Increasing abdominal pain, distension, guarding, a rising pulse and falling pressure over hours is the developing intra-abdominal bleed or perforation. Repeated examination by the same observer is what detects it.
A deformed limb is assessed for pulses, sensation and movement first, because vascular or nerve injury is what causes permanent loss. Straightening and splinting a limb with no pulse is urgent.
Pain far worse than the injury warrants, worsening despite analgesia, and worse on passive stretching means pressure in a muscle compartment is destroying it. Pulses are present until late, and the limb is not elevated above the heart.
A fracture with a wound over it communicates with the outside and needs cleaning, covering, antibiotics and surgery promptly. Its infection risk, not its appearance, sets the urgency.
Splinting reduces pain, bleeding and further tissue injury and makes transfer possible. It is a clinical intervention rather than a step that can wait for imaging.
A limb crushed or compressed for hours releases substances that injure the kidneys, so somebody found collapsed after a long period on a hard floor is at risk even without a fracture. Fluids and urine monitoring are the point.
Running water for a substantial period reduces the depth of the burn, and it is effective even somewhat delayed. Ice causes further damage, and nothing else — oil, toothpaste, ash, butter — goes on it.
Soot around the mouth or nose, singed facial hair, a hoarse voice, stridor, burns in an enclosed space, or difficulty swallowing. The airway swells over hours and is secured before it becomes impossible, not after.
Extensive burns lose large volumes of fluid and need calculated replacement, and under-resuscitation kills. Estimating the area affected is an urgent clinical assessment rather than paperwork.
Superficial burns are red and painful, deeper ones blister, and the deepest are white or charred and painless because the nerves are destroyed. A painless burn is a deep one, which is counterintuitive and important.
Chemicals need prolonged irrigation and identification, electrical injury causes damage along its path including to the heart, and burns whose pattern does not match the explanation require safeguarding assessment.
The harm in drowning is lack of oxygen, so the priority is ventilation and oxygenation rather than any attempt to remove water from the lungs. Deterioration can occur hours later, so survivors are observed.
Profound cooling slows everything and people have survived long submersion in cold water, so resuscitation is continued while rewarming. A cold patient is not declared dead on the usual criteria alone.
A very cold heart is irritable and rough handling can precipitate a fatal rhythm, so movement is minimal and deliberate. Rewarming is gradual, and the core is warmed before the periphery.
Heat exhaustion with weakness, sweating and headache progresses to heat stroke with confusion, a very high temperature and collapse, which is rapidly fatal. Cooling begins immediately rather than after investigation.
Outdoor workers, older people in unventilated housing, athletes, and people on certain medicines. It is increasing, it is predictable, and prevention is mostly information nobody was given.
Airway, breathing, circulation and glucose come before identifying the substance. Many poisonings have no specific treatment, and supportive care is what saves the patient.
The substance, the quantity, the timing, whether alcohol was involved and whether more than one thing was taken. Time since ingestion determines what treatments are still useful.
A small number of poisonings have antidotes whose timing is critical, including common painkillers whose overdose causes liver failure without early symptoms. Feeling well after that overdose is not reassuring.
People under-report, misremember, and take several things. A presentation that does not fit the stated substance is taken as evidence that something else was involved rather than that the patient is exaggerating.
Physical treatment and psychosocial assessment are both required, and a patient discharged medically fit without the second has been half treated. The period after an attempt carries high risk.
Chest pain is treated as cardiac until shown otherwise, because the cost of being wrong is asymmetric. Rapid assessment, an early heart tracing and observations are the priority.
Women, older people and people with diabetes frequently present with breathlessness, fatigue, nausea or upper abdominal discomfort rather than classic chest pain. These presentations are diagnosed later and treated worse.
An early heart tracing identifies the pattern requiring immediate treatment, and every minute of delay costs heart muscle. Obtaining and showing it to somebody who can interpret it is a nursing responsibility.
A normal initial tracing occurs in a substantial proportion of heart attacks, so a patient with a convincing history is not reassured and sent home. Serial tracings and blood tests exist for this reason.
A tear in the main artery, a clot in the lung, and a perforated gut all present as chest pain and are missed when everything is assumed cardiac. Tearing pain radiating to the back, or breathlessness with a swollen leg, redirects the thinking.
Asthma, chronic lung disease, heart failure, pneumonia, a clot in the lung, anaemia, acidosis and anxiety all present with breathlessness, and several of them kill within the hour. The assessment separates them.
Speech in short sentences, use of neck and abdominal muscles, sitting forward, exhaustion, a silent chest in asthma. A patient too breathless to speak is severely unwell whatever the saturation reads.
In asthma, wheeze indicates air moving; a quiet chest in a distressed asthmatic means almost no air is moving and is a pre-terminal sign. Reassurance based on absent wheeze has killed people.
Some patients with long-standing lung disease lose their drive to breathe with high oxygen concentrations, so oxygen is given to a target and monitored rather than turned up or withheld.
Sitting a breathless patient upright, opening a window, calm explanation and staying with them reduces distress and oxygen demand measurably. Panic worsens breathlessness, and a nurse who stays changes that.
A low blood glucose mimics stroke, intoxication, psychosis and head injury, and it is corrected in minutes. Every collapsed or confused patient has their glucose checked, and this is the most reliably rewarded reflex in emergency care.
Heart rhythm, blood pressure, bleeding, poisoning, seizure, low glucose, low sodium, infection, stroke and simple faint. A structured approach prevents fixating on the most visible possibility.
Collapse during exertion, while lying down, without warning, or with chest pain or palpitations suggests a cardiac cause and is not a simple faint. Those features are asked about specifically.
What happened immediately before, whether there was shaking, how long they were out, what they were like afterwards. The witness account frequently makes the diagnosis and the witness frequently leaves before anybody asks.
Somebody who collapsed may have hit their head, fractured a hip or been on the floor for hours. Treating the cause and forgetting the consequences is a common and costly omission.
During a seizure the priority is preventing injury, positioning to protect the airway, and timing it. Nothing is put in the mouth and the person is not held down.
A seizure continuing beyond a few minutes, or repeated seizures without recovery between, causes brain injury and requires urgent treatment. Timing the seizure is therefore a clinical act.
Drowsiness, confusion, agitation and a headache follow a seizure and can last a considerable time. That state is expected and is not itself evidence of another problem, though it is reassessed.
Low glucose, low sodium, alcohol withdrawal, drugs, head injury, infection, pregnancy-related causes and stroke. A first seizure in an adult always has a cause to be sought.
Seizures in later pregnancy or shortly after delivery may be a specific obstetric emergency with its own treatment, and it is immediately life-threatening to mother and baby. Recognising the setting is the whole thing.
Treatments that restore blood flow work only within a limited window from the onset of symptoms, so the time the symptoms began is the single most important piece of information in the assessment.
Sudden facial weakness, arm weakness, speech difficulty, visual loss or severe unexplained imbalance. Sudden onset is the key feature and the patient frequently minimises it.
Low glucose, seizure, migraine, infection and low sodium all mimic stroke, which is why glucose is checked immediately and why assessment is rapid rather than assumed.
In a patient who woke with symptoms, the relevant time is when they were last seen well, not when they woke. That distinction determines eligibility for treatment and is frequently recorded wrongly.
A stroke patient is not given food, drink or oral medicine until swallowing has been assessed, because aspiration pneumonia is a leading cause of death after stroke. This is a nursing decision with mortality attached.
Severe abdominal pain with a rigid, tender abdomen, fever, a fast pulse and a patient lying very still suggests perforation or peritonitis. Movement makes it worse, which is why they do not move.
A ruptured aneurysm in an older person with back or abdominal pain and collapse; an ectopic pregnancy in any woman of reproductive age with abdominal pain; a twisted bowel or testicle. Each is time-critical.
Any woman of reproductive age with abdominal pain has pregnancy considered and tested for, regardless of what she says about its likelihood. Ectopic pregnancy kills and presents exactly this way.
Withholding analgesia from a patient with abdominal pain to preserve the examination is an outdated practice that causes unnecessary suffering without improving diagnosis. Treating pain is correct.
An older person with a perforated bowel may have modest pain, no fever and a soft abdomen, and look far better than they are. A high index of suspicion is what compensates.
Sudden onset, with airway swelling, breathing difficulty or a fall in blood pressure, usually with skin changes, after exposure to a trigger. It is the combination and the speed that identify it.
Anaphylaxis is treated immediately on recognition, because delay is the principal cause of death from it. Waiting to be certain is the error that appears in every review of these deaths.
A patient with anaphylaxis and low blood pressure is laid flat with legs raised, and sitting or standing them up can cause immediate cardiac arrest. This is a specific and under-known fact.
Symptoms can return after apparent recovery, which is why patients are observed for a period and given a plan and a means of self-treatment on discharge. Discharging somebody without that is incomplete care.
Food, drug, sting or latex, recorded precisely and prominently, and the patient told explicitly what to avoid. A vague allergy record is the beginning of the next reaction.
Snakebite kills and disables very large numbers of people worldwide, overwhelmingly poor rural agricultural workers, and antivenom is frequently unavailable or unaffordable. It is among the most neglected of emergencies.
The bitten limb is immobilised at heart level and the person moved calmly to care. Cutting, sucking, applying tourniquets, ice or electricity cause harm and are still widely practised.
Some venoms cause bleeding and tissue destruction, others cause paralysis beginning with drooping eyelids, difficulty swallowing and then breathing. Recognising progressive weakness early is what allows ventilation in time.
Bites introduce organisms deep into tissue and frequently become infected, particularly hand bites. Cleaning, assessment for structures beneath, and consideration of rabies and tetanus where relevant is the standard.
Prompt wound washing and the correct course of treatment after exposure prevent a disease with essentially no survival. Knowing that washing the wound thoroughly matters is worth teaching to everybody.
Children maintain blood pressure remarkably well and then deteriorate suddenly, so blood pressure is a very late sign. Respiratory rate, heart rate, capillary refill and how the child behaves are the earlier measures.
A child who will not feed, is floppy, is inconsolable, does not respond to a parent, or has stopped playing is seriously unwell. A child who is playing is powerfully reassuring, and neither fact appears in a set of observations.
A parent saying this is not like her, or that the child is different from previous illnesses, detects deterioration earlier than the chart in documented cases. Dismissing it is a recognised route to a death.
Spots that do not fade under pressure in a febrile child is an emergency, and in suspected meningococcal disease the rash appears late or not at all. A very unwell febrile child is treated without waiting for it.
Injuries inconsistent with the explanation or the child's developmental stage, delayed presentation, or a bruise in a baby who is not yet mobile require safeguarding assessment alongside treatment. Both happen; neither replaces the other.
Infection without fever, heart attack without chest pain, perforation without a rigid abdomen, and almost everything as confusion or a fall. Expecting the classic picture is how serious illness is missed here.
Somebody who fell has a reason — infection, medicines, rhythm disturbance, blood pressure dropping on standing, weakness, dehydration. Treating the injury and discharging them returns them next week.
A long period on the floor causes dehydration, pressure damage, muscle breakdown, kidney injury and hypothermia. That single question changes the whole assessment and is rarely asked.
Trolleys, noise, bright light all night, no glasses or hearing aid, no food, and no sleep produce delirium, pressure damage and deterioration within hours. Length of stay in the department is a clinical risk for older people.
An accurate medicine list and somebody who knows their normal function transform the assessment. Asking a relative to bring both is a useful instruction at first contact.
People in crisis, after self-harm, intoxicated, psychotic or suicidal are a substantial part of emergency work, and they consistently report being treated worse than patients with physical problems. That is a solvable failure.
Low glucose, infection, head injury, low sodium, thyroid disease, drugs and withdrawal all present as agitation, confusion or psychosis. A physical assessment is not a delay before the psychiatric one, it is part of it.
Asking plainly whether somebody has thought of ending their life does not plant the idea, and it is the only way to find out. People frequently answer honestly when asked directly and never volunteer it otherwise.
That framing is inaccurate and it worsens care. People who self-harm have a substantially raised risk of later death by suicide, which makes every presentation a clinical opportunity rather than a nuisance.
Physical and chemical restraint cause injury and death, and the safest de-escalation is space, time, a calm voice, fewer people and meeting a need. Where restraint is unavoidable, monitoring afterwards is mandatory.
Domestic abuse, child abuse, elder abuse, trafficking, sexual assault and neglect present here, frequently as something else. Asking, privately and routinely, is how it is found.
Nobody discloses abuse in front of the person accompanying them, and the accompanying person is sometimes the one causing harm. Creating a private moment is the single most important condition for disclosure.
A disclosure met with doubt, questioning of details or visible discomfort ends the conversation and frequently ends any future one. Believing, recording the person's own words, and knowing the local pathway is the response.
Injuries inconsistent with the explanation, injuries at different stages of healing, defensive injuries, injuries to the head, neck and forearms, repeated attendances, and delayed presentation.
Records of injuries, described in the patient's words with measurements and where consent allows photographs, may be used in a legal process years later. Writing carefully is part of protecting somebody.
Families arrive with no preparation and learn of a death in a corridor or a relatives' room within minutes of a normal day. How that is done is remembered permanently by everybody present.
Euphemisms leave families uncertain whether the person is dead. Saying clearly that they have died, using their name, and then allowing silence is what actually communicates it.
Time with the person, being allowed to touch and hold them, and privacy without being hurried matters enormously and costs a room. Religious and cultural requirements around the body are asked about rather than assumed.
The death of a child requires particular care with the parents, with the other children, with the staff involved, and with the legal and investigative processes that follow. Nothing about it is routine.
Staff who have resuscitated somebody unsuccessfully, particularly a child, go straight back to a full department. A brief acknowledgement, and a proper opportunity to talk later, reduces lasting harm.
Emergency department crowding is associated with increased mortality, delayed treatment, more errors and worse pain control. It is a patient safety issue rather than an inconvenience, and saying so is legitimate.
Patients deteriorate in waiting rooms, and systematic reassessment is the only defence. It is the first thing abandoned under pressure, which is precisely when it is most needed.
People tolerate long waits considerably better when told honestly how long and why, and being ignored is what produces aggression and complaints. Information is a low-cost intervention with real effect.
People who do not speak the language, who are poor, who have mental health problems, who are intoxicated, who are homeless, or who cannot advocate for themselves. That pattern is documented and it is correctable.
Judging whether somebody should have come is not a clinical function, and the instinct to do so worsens care for exactly the people who have least access to anything else.
Emergency staff are verbally abused and physically assaulted at high rates, and this is not an acceptable part of the job. Reporting it, and expecting it to be acted on, is reasonable.
Repeated exposure to death, injury, children's deaths and violence produces traumatic stress, and it accumulates rather than resolving between shifts. It is a predictable occupational consequence, not a personal weakness.
Night work, missed breaks, dehydration and constant interruption impair decision-making and health. Errors rise with fatigue, which makes rest a patient safety measure.
Structured opportunities after difficult cases help, and the informal support colleagues give each other does most of the work. Both need protecting rather than fitting into gaps.
People become blunted by this work and recover with rest, acknowledgement and support. Treating that as a character flaw rather than a predictable state is what drives people out of emergency care.
The primary survey order, triage and reassessment, anaphylaxis recognition and position, stroke onset time, the non-blanching rash in a child, glucose in every collapse, and head injury on anticoagulants.
Waiting for certainty before treating anaphylaxis; sitting up a hypotensive anaphylactic patient; reassurance from an absent wheeze in asthma; using wake-up time rather than last-seen-well in stroke; discharging a head injury on blood thinners because they look well; attributing an older person's fall to clumsiness; assuming a head injury explains confusion without checking glucose.
Airway, breathing, circulation, disability, exposure — treating as you find. Check the glucose. Stop the bleeding with pressure. Keep the trauma patient warm. Re-triage those waiting. Ask when they were last seen well.
Count the respiratory rate at triage. Ask how long they were on the floor. Ask the accompanying person to step out. Write the patient's own words. Tell people how long they will wait and why.
Emergency nursing is the discipline of taking a first look properly, in a fixed order, on somebody you know nothing about, and then looking again. Almost every miss in this manual is a survey that was done once.
Written in plain sentences on purpose. Nursing is studied in a second language by a large share of the students who will read this, and a sentence that has to be decoded twice is a sentence that teaches less.
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