In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of emergency response plans in order to:

  • Determine which client(s) to recommend for discharge in a disaster situation
  • Identify nursing roles in disaster planning
  • Use clinical decision-making/critical thinking for emergency response plan
  • Implement emergency response plans (e.g., internal/external disaster)
  • Participate in disaster planning activities/drills

One of the major roles of health care facilities entails the authorship, review and implementation of emergency response plans for all possible and anticipated circumstances. Many components of these internal and external disaster plans are driven by the regulations and requirements of external regulatory bodies such as the US government, the states and the Joint Commission on the Accreditation of Health care Organizations.

The two major categories of disasters that require an emergency response plan are internal disasters and external disasters.

Internal disasters are events within the facility that jeopardize the health and safety of patients, staff, visitors and others. Examples of internal disasters include:

  • Fires
  • Utility failures
  • Workplace violence
  • Tornados, cyclones, hurricanes and other severe storms and flooding
  • Explosions and bomb threats
  • Radiation contamination and
  • Acts of terrorism and bioterrorism in the health care facility

External disasters are serious events which occur in the nearby community that leads to mass causalities and people in need of medical attention and care. A crash of a jumbo jet and a major train derailment are examples of external disasters.

Tornados, cyclones, hurricanes and other severe storms and flooding are examples of both internal and external disasters. For example, Hurricane Katrina is an example of a catastrophic event that can be considered both an internal disaster and an external disaster. It was an internal disaster because many health care facilities in New Orleans were adversely affected with flooding and power losses. It was also an external disaster because there were many injured and ill patients in the community that required the care and services of the health care system.

Other examples of external disasters include acts of terrorism and bioterrorism in the community, such as the Boston Marathon terrorist bombing and radiation spills and accidents.

Determining Which Client(s) to Recommend for Discharge in a Disaster Situation

Nurses use their critical thinking and triage techniques to determine which clients they should recommend for discharge in the event of an internal disaster and in the event of an external disaster that will require the reallocation of staff, client beds, and clinical care areas.

In descending order of priority from the most severe to the least severe type of client, the following clients should be selected for discharge and relocation during an external disaster when unexpected admissions of victims with varying degrees and severity of injury occur as a result of the massive casualty event in the community.

  • Unstable clients: Unstable clients are the most severe and, as such, are not candidates for discharge or transfer to another nursing care unit or relocation.
  • Stable clients: Stable clients who continue to need nursing and medical care and assistance are the second priority and, therefore, should not discharged until the lowest priority clients are discharged or transferred and there is a continued need for more reallocation of resources because higher acuity and higher priority clients need necessary care and services during the disaster.
  • Ambulatory clients and self care clients: Ambulatory clients and self care clients who need little or no assistance are the first clients to be safely discharged, transferred or relocated.

Identifying Nursing Roles in Disaster Planning

Nurses, assistive personnel and all other personnel in health care facilities have specific roles in internal and external disasters, as outlined and detailed in the health care facility's emergency preparedness and emergency response plans. It is highly important that all staff know their roles and responsibilities before a disaster occurs because there is little time to read a policy and procedure when a disaster actually does occur. Immediate and competently executed actions are necessary.

Actions that must be taken for various internal disasters will be discussed now:

Fires and Fire Prevention

Fire prevention in health care facilities includes the education and training of staff, smoke detectors, sprinkler systems, fire doors and policies and procedures relating to fires and fire threats including no smoking policies, oxygen and medical gases use, maintenance and storage policies and procedures, and electrical safety policies and procedures.

The procedure for dealing with and managing patients during a fire is easily remembered with the acronym RACE. You MUST RACE when a fire starts. RACE includes these elements in correct sequential order of priority

  • R: Step number one is rescue everyone in danger; get all clients and visitors out of danger by following the fire plan set up and established by the facility you work in.
  • A: Step number two is pull the fire alarm
  • C: Step number three is to contain the fire in the smallest possible area by closing all windows and doors. This prevents the fire from spreading to other areas of the health care facility.
  • E: Step number four is extinguishing the fire when it is small enough to do so safely.

Step one, which is rescuing everyone in danger, may mean that nurses and other members of the nursing team must follow instructions for a vertical or horizontal evacuation of patients. When patients are moved from one level or floor of the health care facility to another floor, it is referred to as a vertical evacuation; and when you move patients from one area of the floor to another area on the same floor, it is referred to as a horizontal evacuation. Elevators are never used to evacuate because elevators are for the exclusive use of fire fighters and the equipment that is necessary to extinguish the fire.

All medical facilities and households must have fire extinguishers. The different type of fire extinguishers and their uses will now be discussed.

  • A Type A fire extinguisher: A Type A fire extinguisher is used to put out fires on common solid things like paper, mattresses and cloth including clothing. This type of fire extinguisher is somewhat limited.
  • A Type B fire extinguisher: A Type B fire extinguisher is used to fight oil, gasoline and grease fires, including kitchen grease fires. It too is limited in terms of its use. For example, a Type B fire extinguisher cannot be used to combat an electrical fire.
  • A Type C fire extinguisher: A Type C fire extinguisher is used to extinguish electrical fires
  • Type AB fire extinguishers: Type AB fire extinguishers combine the uses of a type A and type B fire extinguishers. They can be used on solids, like paper, wood, cloth as well as oil, gasoline and grease.
  • Type ABC fire extinguishers: Type ABC fire extinguishers are a combination of A, B, and C uses. They are used for all types of fires. They are the ideal choice for home and in most areas of a health care facility.

It is required for all fire extinguishers to be checked regularly to insure that they are fully charged and ready to use in an emergency.

Using a fire extinguisher is quite simple if you remember and use the acronym PASS which is:

  • Pull the pin on the fire extinguisher.
  • Aim at the bottom of the fire.
  • Squeeze the trigger on the fire extinguisher to release the spray and then
  • Sweep the spray from side to side over the base of the fire until it is extinguished.

When a person has clothing that has caught on fire, the person should STOP, DROP AND ROLL. Tell the person, to STOP, DROP, and to not run, and as you also cover the person with a blanket to smother the fire.

GET LOW AND GO if a room fills with smoke. Smoke and heat rise so get to the floor and crawl out.

Utility Failures

The major complications of utility failures are the abrupt cessation of electrical power to essential medical equipment such as a mechanical ventilator, suctioning apparatus and oxygen supplementation systems as well as a disruption of communication systems. Telephone, fax and computer abilities are hampered and even the patients' ability to communicate with staff using their bedside intercom system and their call bell is inactivated when a power outage and electrical systems fail. When this occurs, the nursing team must continuously visually monitor patients by walking up and down the hallways and also providing patients with other forms of communication such as a mechanical bell so that they can continue to alert staff about their needs.

Workplace Violence

Workplace violence can occur among and between workers, patients and visitors. Disturbed, aggressive behaviors that threaten others must be addressed by deescalating the situation whenever possible and by preventing these episodes of violence with security measures such as deterring video surveillance and security guards.

When an episode of workplace violence is possible or actually occurring, the nurse must follow the procedures that address this internal disaster. The prevention and management of disturbed behavior will be discussed later in this course with the section entitled “Psychological Integrity”.

Weather Related Emergencies

Generally speaking, severe storms such as tornados and cyclones are addressed by moving the clients and staff to the center of the area away from windows, by closing windows, curtains, and blinds, by closing interior doors to protect patients from flying debris and by evacuating the area and/or building when you are officially told to do so.


Explosions can occur as the result of both nefarious and accidental means. For example, terrorists may plant a bomb in the facility and an accidental explosion of a medical gas can also occur.

Bomb Threats

Additionally, bomb threats can be called into the facility. If you receive a bomb threat by telephone, stay on the line with the person as long as possible while you are alerting others to this threat. Staying on the line gives you time to collect data and information about the person including their gender, where and when the bomb is to be detonated, and any background noises that may lead to the location of the caller.

Radiation Contamination

Radiation contamination can also occur as the result of a nefarious act of terrorism or by accidental means such as those that may occur in areas such as the nuclear medicine department. All facilities have policies and procedures relating to exposures to radiation, including those recommended by the Centers for Disease Control and Prevention (CDC).

The CDC recommends that everyone evacuate the area, remove outer clothing, place clothes in a plastic bag to contain the radiation, and wash or shower all exposed bodily parts.

Many health care facilities have decontamination areas with showers in the nuclear medicine department and/or the emergency departments to use in the case of radiation contamination.

Acts of Terrorism

Terrorism, such as what happened with the World Trade Center and the Boston Marathon, is described as the purposeful and terroristic use of violence and force against people and property. Terrorism can be done with mechanical means like an airliner or bomb, with chemical, nuclear and radiological weapons and also with biological pathogens. The latter is referred to as bioterrorism.


Agents of bioterrorism, their signs, symptoms and treatments are too complex and extensive to cover in this review, however, you should be familiar with those that are the most likely. Some of these agents include anthrax, botulism, plague, smallpox, tularemia and viral hemorrhagic fevers like yellow fever and Ebola.

General guidelines in terms of responding to a bioterrorism attack include the basic principles of isolation, standard precautions, cleaning, disinfection and sterilization, as indicated by the bioterrorist microbe.

The Nurse's Role in Responding to External Disasters

Health care facilities respond to internal disasters and external disasters that occur as the result of a mechanical, chemical, nuclear, radiological and biological means. Physical injuries that affect large numbers of people are triaged according to the severity of their injuries and their prognosis in terms of certain death or the possibility of sustaining life with treatment. Triage is a method of prioritizing care during massive external and internal disasters. Color coded tags are often used; these tags alert the staff to the severity of all arriving victims and their potential for survival.

Triage colored tags that are black identify the expectant group of victims that is expected to die. This group of victims is given pain medications to provide comfort at the moment and no other further treatments until the red colored tagged clients' needs are addressed. Red colored triaged tags are the immediate care group that requires immediate medical attention for life threatening injuries. This group has a greater possibility of survival than the black tagged group. The yellow triage color indicates that treatment can be somewhat delayed until the red group's needs are addressed. This group is referred to as the yellow tagged group. Lastly, the green triage group, referred to as the minimal care group, has only minor injuries. Like the yellow group, their needs can be delayed until clients with greater needs have been treated.

Using Clinical Decision Making and Critical Thinking for Emergency Response Plans

Professional judgment, critical thinking and sound decision making are some of the essential skills that the registered nurse must readily and competently use in terms of their responses to internal and external disasters.

For example, the registered nurse utilizes professional judgment, critical thinking and sound decision making when they:

  • Triage clients
  • Recommend the transfer or discharge of clients during an emergency
  • Lead and direct others with authoritarian leadership to insure the safety of clients, staff and visitors
  • Perform their other roles and responsibilities relating to internal and external disasters

Implementing Emergency Response Plans

Nurses must be highly prepared to fulfill their roles and responsibilities in terms of all internal and external disasters including those just discussed.

One way to prepare is to review the policies and procedures relating to your role on a regular basis and another way to prepare is by participating in mock drills and practices within the organization.

Some facilities have secret code names for disasters and other emergencies. These secret code names, like Code Blue for a cardiac arrest, communicate the nature of the emergency or disaster to staff without alarming patients, visitors and others who are not staff. Whenever you hear this announcement you must act as if it is a real emergency rather than taking it lightly. If you learn later that it was a drill, you have gotten the opportunity to practice and if you later learn that this announcement indicated a real emergency, you have acted in a way that you should have to fulfill your assigned roles and responsibilities.

In addition to Code Blue for a cardiac arrest, many facilities also use Code Red for fire, Code Gray for a severe weather storm, cyclone or hurricane, Code Orange for a chemical spill and Code Pink for an infant abduction.

Participating in Disaster Planning Activities and Drills

All nurses, including registered nurses, and other health care professionals play an important role in internal and external disasters and emergency preparedness. Registered nurses are also frequently asked to participate as a member of a work group or committee in order to generate, evaluate and revised internal and external disaster plan and also to:

  • Educate staff and clients in relationship to their roles during a disaster or emergency
  • Participate in ALL disaster and emergency practice drills
  • Participate in the planning. Implementation and evaluation of disaster and emergency practice drills

The Joint Commission on the Accreditation of Health Care Organizations and other regulatory bodies mandate that all health care facilities have emergency response plans and that these plans are taught and evaluated with drills and testing at least twice a year.


SEE – Safety & Infection Control Practice Test Questions

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