3.5 Emergency Response & Prioritization

Recognizing Clinical Deterioration

A large share of CPNRE/REx-PN scenarios test whether the PN can spot a client going downhill before arrest. The earliest warning signs are often subtle. A rising respiratory rate is frequently the first vital sign to change, and new confusion, restlessness, or agitation can signal early hypoxia long before oxygen saturation crashes or blood pressure falls. Learn to read trends, not single numbers.

Classic deterioration patterns tested on the exam:

• Hypoxia: SpO2 falling (for example, 92% to 85% in a client with COPD), rising respiratory rate, restlessness.
• Internal hemorrhage: increasing abdominal pain with tachycardia and hypotension after a procedure such as a liver biopsy.
• Shock: hypotension, tachycardia, pallor, cool clammy skin, and diaphoresis — do not dismiss this cluster as "just anxiety."
• Postpartum hemorrhage: a boggy (soft) uterus with increased bleeding indicates uterine atony — massage the fundus first.

When a client destabilizes, the correct answer is almost always to act now, reassess, and notify the prescriber, not to document and wait.

Prioritizing Multiple Clients — ABCs then Maslow

When deciding which client to assess first, apply two frameworks in order:

1. ABCs — Airway, Breathing, Circulation. A threat to airway or breathing outranks everything else.
2. Maslow's hierarchy — physiological needs before safety, and safety before psychosocial needs (love/belonging, esteem).

Layer on three tie-breakers: acute beats chronic, unstable beats stable, and actual problems beat potential (at-risk) problems.

So a client with a dropping oxygen saturation is assessed before a post-op client with expected 5/10 pain, a new diabetic awaiting teaching, or a stable client wanting discharge paperwork.

Triage Principles

In the emergency department, Canada uses the Canadian Triage and Acuity Scale (CTAS), which sorts clients into five levels: Level 1 Resuscitation (immediate, life-threatening), Level 2 Emergent, Level 3 Urgent, Level 4 Less urgent, and Level 5 Non-urgent. Lower number = higher acuity = seen sooner.

In a mass-casualty or disaster situation, triage flips to doing the greatest good for the greatest number using colour-coded tags:

• Red — Immediate: life-threatening but survivable with quick intervention.
• Yellow — Delayed: serious but can wait a short time.
• Green — Minor: the "walking wounded."
• Black — Expectant/deceased: injuries incompatible with survival given available resources.

Basic Emergency Response — CPR and Choking

For an unresponsive adult with no pulse, follow Basic Life Support (BLS): check responsiveness, call for help / activate a code blue, and begin C-A-B — Compressions, then Airway, then Breathing. Give compressions at a rate of 100-120 per minute, at least 5 cm deep, at a 30:2 compression-to-ventilation ratio, and attach an AED as soon as it arrives, minimizing interruptions.

For choking (foreign-body airway obstruction): if the adult is conscious with severe obstruction (cannot speak, cough, or breathe), deliver back blows and abdominal thrusts (Heimlich manoeuvre). If the client becomes unconscious, lower them safely and begin CPR. A client who can still cough forcefully has a partial obstruction — encourage coughing and do not intervene.

Always check code status first: a valid do-not-resuscitate (DNR) order means CPR is not initiated; the nurse provides comfort measures and notifies the team, and does not need family permission to honour the existing order.

Rapid Response, Codes, and First Actions

A Rapid Response Team (RRT) is called for a client who is deteriorating but has not yet arrested — the goal is to intervene early and prevent a code. A code blue is called for actual cardiac or respiratory arrest. Common hospital code colours include code red (fire), code white (violent/aggressive person), code orange (disaster/mass casualty), and code black (bomb threat), though exact colours vary by facility.

For fire, use RACE: Rescue/remove clients in immediate danger, Alarm (activate and call), Contain (close doors), Extinguish or Evacuate. To use an extinguisher, remember PASS: Pull the pin, Aim at the base, Squeeze the handle, Sweep side to side.

The universal first action in any crisis is to stay with the client, ensure immediate safety, apply the ABCs, and call for help — never leave an unstable client to find assistance yourself; use the call bell or send a colleague.

A Worked Prioritization Scenario

Suppose the PN must respond to three simultaneous concerns: (1) a client with new-onset shortness of breath and an SpO2 of 84%, (2) a client whose IV pump is alarming for an occlusion, and (3) a client asking for help to the bathroom. Apply the ABCs first: the client with shortness of breath and low saturation has a breathing problem and is seen first — position upright, apply oxygen if ordered, and reassess. The IV occlusion is a task problem that can wait briefly and may be handled next, while the bathroom request — a safety/comfort need for a presumably stable client — can be delegated to a UCP. Notice how prioritization and delegation work together: recognizing the emergency frees the PN to hand lower-acuity, predictable tasks to the appropriate provider.

Common Emergency and Prioritization Traps

• A rising respiratory rate and new restlessness are early deterioration signs — do not wait for blood pressure to fall before acting.
• Do not label a shock picture (hypotension, tachycardia, pallor, diaphoresis) as "just anxiety" — act and notify the prescriber.
• Documentation never comes before intervention in an unstable client; the correct first action is to assess, stay, and escalate.
• A valid DNR order means no CPR — provide comfort measures; family permission is not required to honour the order.
• Airway and breathing outrank circulation, and physiological needs outrank psychosocial ones — the client who can still talk and cough is usually not the priority.