Nursing Care of Clients with Emergent Conditions

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Nursing Care of Clients with Emergent Conditions

• Shock, Trauma, Burns, Hypo/Hyperthermia,
  Poisioning Drug OD, Near-drowning,
  Psychiatric Emergencies

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A,B,Cs of Primary Survey

• Recognize life-threatening conditions and
  determine prioritization of care is mandated by
  an initial assessment
• Aairway
• BBreathing
• Ccirculation Consciousness
• . This Process is known as
• Primary Survey

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Primary Survey

• Airway is most important component use chin-lift
  or jaw thrust maneuver. Plus essential to
  maintain alignment of neck (cervical spine)
  Spinal cord injury?. Neck should never be
  hyper-extended, flexed, or rotated until spinal
  injury is R/O. Next, airway inspected loose
  teeth, foreign objects etc., if present do a
  visible removal with a finger sweep or oral
  suctioning is better

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Primary Survey

• Airways airway adjuncts oral-pharyngeal airway,
  naso-pharyngeal airway- later a mechanical
  ventilation may be used if not breathing- ex.
  Endotracheal tube (ET) or tracheotomy w/
  tracheostomy tube, and or manuel assistance with
  ambu bag and or attached to mechanical
  Ventilator (Respirator)

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Breathing

• After the Patency of the Airway is established
  the client is assessed for spontaneous breathing
• Ventilated with Mouth-to-face mask or
  bag-valve-face mask
• ET used unconscious client
• Spontaneous rise/fall of chest?
• Auscultate breath sounds Clear?

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Circulation Consciousness

• Assess the Carotid pulse? VS?
• Check the skin color, temp, any bleeding?,
  anything compromises circulation? Internal
  bleeding? Shock? Large guage IV catheter (needle)
  is required 16 or 18 g. for IV fluids
• No pulse start CPR
• Unresponsiveness? Painful stimuli applied (
  sternal rub, pressure fingernails, or
  periorbital pressure) any response to pain
  stimuli?

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Secondary Survey

• Severe trauma assess body for injury head,
  neck, chest, abd, and Musculo-skeletal
  head-to-toe assessment clients clothing is
  removed
• Any open wounds, broken bones, bruising, rigidity
  of abd, peripheral pulses present?, movement
  sensation, quick HP done

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Shock acute peripheral circulatory failure

• With inadequate/failing tissue perfusion ( to
  major organs), and subsequent cell death if not
  treated.
• Initially compensatory mechanism kick in ( inc.
  pulse, breathing faster, etc.) but later these
  fail and cellular perfusion decreases, causing
  hypoxemia and finally cell death.
• cardiogenic, hypovolemic, septic, neurogenic
  and anaphylactic

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Clinical indicator of Shock

• Restlessness
• Weak, rapid, thready pulse
• Cold/clammy skin
• Pale, white, or ashen skin color
• Shallow, rapid, labored breathing

• Gradually and steadily failing blood pressure
• Alteration in LOC ( severe shock state)
• Capp. Refill delayed or absent

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Treating Shock
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External hemorrhage Control external bleeding by
applying pressure to local site

• If extremity, elevate to stop venous bleeding
• If bleeding continues, apply direct pressure
• When elevation and pressure doesnt work,
  arterial pressure point control should be
  attempted proximal to injury site
• Apply tourniquet as a last resort

• To control hemorrhage
• Apply a pressure dressing when indicated
• Re-inforce dsg as needed
• Serious trauma cases Pnuematic anti-shock
  garmets or (MAST) military anti-shock trousers (
  raise B/P and stabilize pelvic/femoral Fractures

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Anaphylactic shock

• Foods ( nuts, shellfish, egg whites, chocolate,
  strawberries, etc.)
• Insect bites/stings
• Snake venom
• Drugs antibiotics, vaccines, iodine based-dyes,
  narcotics, local anesthetics, blood transfusions,
  subt latex, pollen,molds, food additives

• Client is exposed to an antigen body produces
  antibodies but later exposure client becomes
  sensitized and anaphylaxis may occur

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anaphylaxsis

• Allergic hypersensitivity reaction
• Stimulates mast cells to release histamine
  other chemical mediators into circulation.
• Causes widespread vasodilation makes the
  capillaries more permeable ( leakage) with the
  shift of fluids ( from vascular into interstitial
  space with pooling) resulting in hypotension and
  possible vascular collapse!
• No loss of blood volume just vasodilation
• Also get bronchoconstriction ( no air)

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Manifestations of anaphylactic shock

• Cutaneous generalized itching, flushing,
  sensation of warmth, uticaria (hives), angioedema
  ( swelling of eye- lids, lips, and tongue)

• Neuro restless- ness, anxiety, dec. LOC,
  apprehension
• Resp SOB, wheezing, laryngeal stridor, rales,
  cyanosis
• CV hypotension and tachycardia
• GI nausea/vomiting diarrhea

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Immediate Treatment

• Maintain airway and give oxygen _at_ 100
• Epinepherine (Epi) 0.2-0.5 mg of a 11000
  solution given sub-cutaneously
• May be repeated q 10-15 min

• Antihistamines like Benadryl (to control
  uticaria)
• IV Steroids
• Medications given till the s/s of anaphylaxis
  reverses and VS are stable

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Septic Shock

• Results from an overwhelming bacterial infection
  ( psuedomonas, E-choli, klebsiella, Staph
  Strep) ex. Toxic Shock syndrome (TSS)
• Pre-disposing factors include , 1 yr of age and
  gt 65 yrs. Of age, chronic debilitating dz,
  cancer, AIDS, malnutrition, burns or pressure
  ulcers, DM, surgery or invasive procedures, IV
  lines or tubes, drugs like chemo, antibiotic
  therapy, or steroids

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Septic shock begins with septicemia

• Presence of pathogen their toxins in the blood
  which multiply quickly and the body cant kill
  them fast enough
• Endotoxins are released into bloodstream which
  damage tissue and starve cells of oxygen
  nutrients- damaged cells release histamines to
  dilate peripheral vessels and increase capillary
  permeability -leakage pooling ( like
  anaphylaxis)hypotension and microemboli ( tiny
  bld clots)
• Septic shock has early late phase

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Septic Shock 2 phases

• Early (Warm)
• Norm-dec. B/P
• Tachycardia
• Rapid resp
• Warm, flushed dry skin
• Alert to anxious
• Norm. urinary output
• Elevated temperature

• Late ( Cold)
• Profound hypotension
• Rapid, thready pulse
• Rapid, shallow respirations
• Cold, cyanotic extremities
• Confused-lethargic-comatose
• Oliguria to anuria
• decreased body temperature
• Death results from resp, cardio, or renal failure

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TX Septic shock

• First thing is to identify the causative organism
• Using aseptic technique, specimens of blood (
  cultures), urine, wound, sputum are collected for
  C S
• IV fluids to counteract massive vasodilation
  caused by endotoxins, plus IV antibiotics
• Client may need critical care unit

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Neurogenic Shock

• Interruption in the sympathetic nervous system
• May result from damage to vasomotor center in the
  medulla or from loss of impulse transmission in
  spinal cord injury (above T-6 level), or from
  head injury, spinal anesthesia, opiate drug OD,
  hypoglycemia

• Without sympathetic nervous system impulses, the
  blood vessels dilate, leading to massive
  peripheral vasodilation-leakage of
  capilarries-shift fluid-pooling inadequate
  tissue perfusion-organ failure-death

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Cardiogenic Shock

• Caused by failure of the hearts pumping action
• Decrease cardiac output and tissue perfusion
• MI common cause of shock

• Ventricles fail to pump
• Dec. stroke volume (amt of bld ejected from the
  heart/minute
• Blood backs up in lungspulm edema
• Cardiac output decreaseshypo-tenion

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Cardiogenic shock

• General concept
• Dec. COreduced bld flow to coronary
  arterieshypoxia inbalance between oxygen supply
  and demands muscle ischemia, possible
  arrhythmias, and probably a myocardial
  infarction!

• S/S systolic B/P pressure lt 90
• Rapid, weak pulse
• Distended neck veins
• Rapid, labored respirations
• Pale, cold, moist skin
• Restlessness, agitation, or diorientation
• Oliguria or anuria

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TX Cardiogenic Shock

• Oxygen
• Adrenergic drugs vasopressors like Dopamine
  Levophed (nor-epi) and Positive inotropic drugs
  (b-adrenergic) increase force of contraction to
  inc. Cardiac output like Dobutamine

• Other drugs NTG, Digoxin, Nipride, and
  anti-arrhythmic drugs, and diuretics
• 2-mechanical devices severe cases (
  IABP-intra-aortic balloon pump and
  (VAD-ventricular assistive device)

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Hypovolemic Shock

• Most common type caused by a decrease in
  intravascular volume
• Causes Hemorrhage ( loss of bld volume) due to
  trauma, major Fx of pelvis femur, surgery, GI
  bleeding, hemothorx

• Internal fluid shifts (third spacing) ascites,
  intestinal obstruction.
• Burns (loss of plasma proteins thru the skin)
• Dehydration (body fluid loss) diuresis from
  diuretics, diabetes insipidus GI loss via
  vomiting, diarrhea, continuous NG suctioning,
  prolonged inadequate fluid intake

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Hypovolemic shock

• Main goal is to restore volume
• IV fluids used alone or in combination with
  colloids, blood, or blood products
• Usually given ratio of 31 ( 300ml for every
  100ml fluid loss)

• Pnuematic anti-shock garmets applied (MAST)
• TX needs to begin within 1st hour golden hr
• Adm IV fluids both crystalloid colloid and or
  blood products

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Fluid replacement

• Colloid solutions
• Plasma expanders
• Contain proteins that increase oncotic pressure
  (oncotic pressure holds fluids within the vessel
  so that the plasma volume expands)
• -Albumin 5 or 25
• -Plasma protein fraction Plasmanate
• -Dextran or Gentran or Hespan
• (albumin and PPF come from human donors, others
  synthetically made)

• Crystalloid solutions contain electrolytes
  dissolved in water ex. 0.9NS and Lactated
  Ringers solution
• Both isotonic increase volume intra-vascular and
  interstitial spaces
• Large volume of fluids may lead to FVE and or
  Pulmonary Edema- monitor for respiratory distress
• Usually first fluids given till bld or plasma
  expanders are used

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Burns thermal, Chemical or electrial

• Initially have decrease blood flow to area with
  vasodilation and increased capillary permeability
  fluid leaks out into interstitial space
• May place the client to hypovolemia and shock

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Burns burn depth partial or full thickness

• Superficial (1st degree) epidermis only, with
  pink-red tones pain edema like a sunburn or
  radiation burn w/ chills, h/a, n/v. Skin is
  intact
• Split or Partial thickness (2nd degree) involve
  the epidermis dermis, and skin is red with pain
  ( serious-sunburns, blistering)
  painful, skin function absent
• Full-thickness (3rd degree) involves all layers
  of the skin ( epidermis dermis) and the
  subcutaneous tissue hair follicles. Skin
  appears white or charred, red or brown, leathery.
  May be painless d/t nerve endings destroyed,
  however surrounding tissue will be painful and
  sensitive to air. Use the Rule of Nines to
  determine the of total body surface area burned
  (TBSA). May require excision of eschar or skin
  grafting to heal

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Guidelines for burns

• Immediately irrigate burn area with water
• If chemical burn to eyes flush eyes for 5 min
  alkali burn 10-20 min and then seek medical help
  fumes of strong chemicals cause pulmonary burns

• Initiate A,B,Cs
• Good history of what happened
• Keep a trach set close if resp. distress occurs
• Keep warm, never apply cold packs or ice on the
  burn can cause thermal tissue damage

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Guideline for burns

• Maintain IV access for fluids
• May give IV narcotics (pain)
• For partial-thickness burns Use sterile saline
  solutions and antibiotic creams such as silver
  sulfadiazine or Silvadene and dsg.

• Hydrotherapy is often used
• Monitor Fluids and electrolytes
• Long process for full-thickness may require skin
  grafting

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Hyper/Hypo-thermia

• Hypothermia-core body temp falls below 95 F. or
  35 C.
• Shivering, clumsy, irritable, may progress to
  changes LOC, pupils dilate, cardiac problems

• Hyperthermia- occurs when body unable to
  dissipate heat
• 100.4 F-106 F
• Children and geriatrics at greatest risk
• Fluids are very important

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Treatment

• Hypothermia
• Remove any wet clothes
• Keep warm with warm blankets
• Cover the head with warm towels or hat
• Heating blanket
• Warmed fluids

• Hyperthermia
• Push fluids
• Start off anti-pyretics for only mild
  hyperthermia
• Cold paks to groin/axilla/back neck
• Cool tepid misting or sponge baths-never icy cold
  which causes shivering more heat
• Cooling blanket
• Monitor s/s confusion, seizures

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Defining characteristics for Heatstroke

• Early signs
• Temp 102-104 F, diaphoresis, cool,clammy skin,
  dizzy, tachycardia
• Late s/s temp reaching 105-106, hot, dry,
  flushed skin, altered LOC, seizures, coma,
  hypotension