Introduction

Emergency nursing care is still in evolution, having first started in out of the way rooms in out of the way places in many hospitals. Only in recent years has the delivery of emergency care been recognized as a needed and valued component of the community and hospital's care delivery system. Rooms have been expanded and there is recognition of emergency departments (EDs). Medical and nursing organizations have developed to recognize the special education and training required for an individual to provide care in an emergency setting. Although many hospitals still staff their ED with "moonlighters" from other specialties, recognition of programs in emergency medicine are coming to the forefront. For nurses, the road has been bumpy as the nurse grapples with an identity that is not quite med-surg, not quite critical care. The Emergency Nurses Association has organized to validate the practice of emergency nursing through standards of practice and care. Emergency nursing practice is a unique opportunity to use and enhance the nursing process skills of anyone willing to be challenged. Emergency nursing practice also challenges the nurse to practice holistic nursing, under emotional conditions in very limited periods of time.

Case studies in this manual take into consideration two aspects of the emergency care structure that have a tremendous impact on practice: (1) the patient generally presents with a complaint of illness or signs and symptoms, rarely with a statement of medical diagnosis; (2) the patient is usually seen first by a nurse who must determine how acutely ill or potentially ill the patient is, and then what resources are appropriate to mobilize to manage that patient's care. Given these factors, a framework for nursing triage based on clustering of complaints, signs, and symptoms by health system and nursing care management based on related nursing diagnoses is used as an organizing model for patient assessment, intervention, and evaluation.

The framework used to organize the case studies for this manual is adapted from the model first introduced at The Johns Hopkins Hospital. Baltimore. Maryland, under the leadership of Reitz in 1982 (1). The model incorporates concepts of health and the dynamics of health status along with the nurse's role in assessing a patient's needs and intervening appropriately. The framework organizes health data into health dimensions and functional health systems. These health systems are further organized into biophysical health functions and behavioral health functions.

Using this framework for patient triage, clustering of symptoms by health systems, and then further organizing the assessment data by degrees of acuity provides a basis for prioritizing care for patients in the ED. This model for triage is adapted from that first organized by Christmyer, Catanzariti, Langford, and Reitz (2) and implemented in their ED. This health parameter concept for use in the ED is not unlike that described by Corrigan (3) which was adapted from the functional health parameter concept presented by Gordon for use with nursing diagnoses (4). The introduction of nursing diagnosis as a means of organizing nursing interventions and evaluating outcomes is a viable enhancement to the nursing process in the ED setting.

The nursing diagnoses chosen for presentation in this manual are based on those endorsed by the Seventh National Conference General Assembly of the North American Nursing Diagnosis Association (NANDA) in 1988.

In this manual, the overview for each chapter discusses the organization of patient complaints and symptoms into biophysical and psychosocial health systems based on this framework for holistic patient care. Levels of acuity are described as they relate to the severity of the patient's illness and consumption of nursing resources to provide care. A general description of the meaning of the acuity levels in the ED setting is presented in Table I. The overview of the health system is then followed by case studies that represent types of patients who are frequently seen in the emergency setting, triaged by health system complaint. Cases are designed to address the patient's chief complaint or symptoms, his or her acuity level, the etiology and physiology of symptoms, pertinent nursing diagnoses for the ED nurse to consider, and independent and interdependent nursing actions to be taken.

As is reasonable, a complete health assessment of the patient is conducted at triage that considers the biophysical. behavioral, and social health needs of the patient. The patient's acuity level is driven by the health system of highest acuity in the cluster of patient symptoms. For example, the patient with normal vital signs may be considered acuity level I in the circulatory health system. However, the patient's report of excruciating headache may rank as acuity level III in both the neurological-cerebral health system and sensory health system, identifying the patient as needing expeditious care.

Table 1 Leveling Process for Differentiating Nursing Acuity Related to Patient Health Systems
Level I	A rating of "1" (minor) indicates minimal or minor care requirements. The patient is generally capable of self-care and may require only minor treatments and few medications The patient is generally ambulatory, and is able to care for him- or herself without assistance; activity is not restricted. The patient exhibits no behavioral deviations but may require minimal health teaching and emotional support. Such patients are frequently referred to other "no urgent" clinics and community resources for assistance
Level II	A rating of "2" (moderate) indicates partial dependence on nursing staff for assistance; periodic observation, treatments, and medication are required The patient may require some activity restriction and some assistance with daily activities The patient may manifest occasional behavioral deviation, i.e., slight contusion The patient requires periodic health education and emotional support. This patient may be referred to some other "no urgent" clinic. More often the patient is provided with a" intermediary level of intervention by the triage nurse and then asked to wait while care is provided to patients in more urgent need of care.
Level III	A rating of "3" (major) indicates a major dependence on nursing staff for assistance The patient requires considerable restriction of activity; may require total assistance " daily activities; may be incontinent; and requires frequent observation, treatments and medications. The patient manifests marked emotional needs, and may require use of protective devices and exhibit severe deviation in behavior, i.e. marked confusion, hyperactivity. The patient may require considerable instruction Patients " this category frequently have significant potential for poor outcome or serious complications if their needs are not addressed in a timely fashion. These patients are given high priority for treatment.
Level IV	A rating of "4" (intensive) indicates requirement for close and continuous observation and monitoring The patient may require life-saving measures administered prompt". and constantly; the patient may exhibit symptoms of extreme behavioral deviation requires rigid activity restriction. The patient is unstable and may be unconscious Patients in this category require immediate intervention Resuscitative measures are frequently undertaken. Medical and nursing resource utilization is maximized to reverse immediate signs and symptoms of catastrophe.

Nursing diagnoses can be determined by analyzing the data collected within each health system and relating those data to the defining characteristics as described by NANDA. Nursing interventions are selected based on an understanding of the etiology and of pathophysiology of the patient's complaint. The nurse in the emergency setting must set priorities as to which diagnoses are most life- or health-threatening to the patient and take immediate action. All nursing diagnoses may not be addressed during the episodic visit. Prioritization must be realistic. Intervention and desired patient outcomes must be achievable. The patient's psychosocial and discharge needs must be considered as pertinent to the treatment plan. Before discharge the nurse must determine that the patient has the intellectual. emotional, financial, and social resources to follow the plan of care adequately. The nurse's knowledge of community resources can assist in providing patient care at home rather than in the hospital. Case files for patients who repeatedly require the services of the ED should be available to all health team members so that the plan of care for the patient can be consistent and dynamic, as needed. The health system framework with related nursing diagnoses makes this possible.

REFERENCES

Reitz JA: Toward a comprehensive nursing intensity index. Part I, Development. Nurs Manage 16(8):21-30, 1985.
Christmeyer CS. Catanzariti PM, Lang-ford AM. Reitz J: Bridging the gap: theory to practice. Part I. clinical applications. Nurs Manage 19(8):42-50. 1988.
Corrigan JO: Functional health pattern assessment in the emergency department J Emerg Nurs 12(3): 163-167. 1986.
Gordon M: Nursing diagnosis: process and application. New York: McGraw-Hill, 1982.