NCSBN – Lesson 8H: Medical Emergencies Study Guide,100% CORRECT

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NCSBN – Lesson 8H: Medical Emergencies Study Guide When a client exhibits an acute change in condition, such as a reduced level of consciousness, it is an emergency situation and requires immedia ... te intervention. First, the client's status must be determined by attempting to elicit a response by physically shaking the client and loudly stating” open your eyes and talk to me” Then, through quick focused assessment, such as neurological assessment: orientation pupil response, ability to follow commands. Most facilities have a rapid response team to assist the staff nurse so this asset should be mobilized next. Because the client should not be left alone, the nurse should call for help and ask a colleague to bring the list of medications along with the client's chart before the rapid response team arrives. Remember primary emergency trauma assessment using “A, B, C, D and E”. The ED nurse will assess airway, breathing, circulation, and disability/neurological function on a person who has experienced a traumatic head injury. The nurse will also examine the client for the presence of any bruising or drainage, particularly of the ears and nose. A supine position is best; the head of the bed may be elevated slightly if not contraindicated. A CT scan is required if the client presents with an abnormal mental status, clinical signs of skull fracture, history of vomiting, or headache. The first priority is to assess the ABCs. Provide supplemental oxygen (and ventilator support, if needed) (STABILIZE the person). Next, an IV infusion is started using a large bore needle; this will allow for blood to be drawn for a toxicology screen as well as IV therapy. Then, a history of the ingestion is needed to guide the provider in planning care. Once the substance is identified, or there is a high index of suspicion, then treatment to reverse or eliminate the toxic substance is begun. The most common symptoms of asthma include tightness in the chest, labored breathing, coughing and wheezing. Rapid and shallow respirations associated with labored breathing indicate the client is losing the strength required to breathe. The intermittent wheezes indicate increased narrowing of the small airways and a worsening condition. This client requires prompt and aggressive respiratory intervention to avoid respiratory failure, including bronchodilators (such as nebulized albuterol), increased oxygen supplementation to maintain a SpO2 of at least 92%, and anti-inflammatory medications (such as IV corticosteroids). The increased mucus in the airways stimulates coughing and can cause coarse crackles; the anti-inflammatory medication and bronchodilator will make breathing and mucus removal easier. The American Heart Association recommends 30 compressions and two breaths. The compression rate is at least 100 beats per minute. Compression-only CPR is recommended for lay persons. Compressions should be one-third to one-half of the chest depth in children. Health care professionals should assess the carotid pulse on children; the brachial pulse is assessed in infants. Cardiac & Respiratory Arrest The nurse is responsible for having the knowledge and skills to make assessments and intervene for clients who are experiencing a cardiac and/or respiratory arrest. Cardiac & Respiratory Arrest Information – Cardiac & Respiratory Arrest The purpose of cardiopulmonary resuscitation (CPR) is to re-establish the CO2 and O2 exchange and maintain adequate circulation. Failure to ventilate within 4-6 minutes can lead to cerebral anoxia and brain damage. • Assessment Findings o Intervention is necessary for clients who are breathless, pulseless and/or unconscious. ▪ Activate the EMS system (if outside a hospital) ▪ Follow the C-A-B (circulation-airway-breathing) sequence ▪ Maintain a compression rate of at least 100 per minute CPR – Compressions: Cardiac & Respiratory Arrest Compression depth and chest wall recoil must be accurate for effective circulatory assistance. • Hand Placement o If the client is an adult, place two hands on the lower half of the sternum. o If the client is a child, place two hands on the lower half of the sternum. o If your client is an infant, place your fingers just below the baby's nipple line. • Compression Depth o The necessary compression depth for adults is at least two inches (5 cm) and for a child it is at least half the child's anterior-posterior diameter or about two inches (5 cm). o The depth for an infant is at least one quarter of the anterior-posterior diameter of their chest or about 1.5 inches (4 cm). o Minimize interruptions in chest compressions. Interruptions should not last longer than 10 seconds. • Chest Wall Recoil o Allow for complete recoil between compressions. Health care providers should rotate who administers compressions every two minutes. CPR – Airway: Cardiac & Respiratory Arrest Effective CPR requires you to maintain an open and patent airway. CPR – Ventilation (Breathing): Cardiac & Respiratory Arrest • For effective ventilation, deliver two breaths using barrier devices, such as a face mask with a one-way valve. Deliver air over one second and watch the client's chest rise. Avoid excessive ventilation. • Ventilation with an advanced airway will be performed at one breath every 6-8 seconds and will be asynchronous with chest compressions. • Compression-to-ventilation ratio: o Adult: 30:2 with one or two rescuers o Children and Infants: 30:2 with a single rescuer or 15:2 with a two health care provider rescuers Defibrillation – Cardiac & Respiratory Arrest • To use an Automated External Defibrillator (AED): o Power "ON" the AED and attach the pads to the client's bare chest. o Only use the adult pads on adults. You can use either the children/infant pads OR the adult pads on children. o Be sure no one touches the client while the AED analyzes the client's heart rhythm. AED will prompt when shock is advised. If no shock is needed, immediately resume CPR starting with chest compressions. Steps to deliver an efficient CPR, when needed: 1. Activate the Emergency Response System (911) 2. Locate and activate the Automated External Defibrillator (AED) 3. Check pulse 4. Start chest compression 5. Open the client’s airway 6. Attempt to deliver rescue breaths The American Heart Association (AHA) recommends that chest compressions be initiated before attempting ventilations when performing cardiopulmonary resuscitation (CPR). While no published human or animal evidence demonstrates that starting CPR with 30 compressions rather than two ventilations leads to improved outcomes, it is clear that blood flow depends on chest compressions. Therefore, minimize delays and interruptions of chest compressions during the resuscitation. Moreover, the nurse can start chest compressions immediately. Positioning the client's head and achieving a seal for mouth-to-mouth rescue breathing takes time. Upper Airway Obstruction – Cardiac & Respiratory Arrest An upper airway obstruction is a blockage of any kind that decreases airflow and oxygenation to the lungs. The nurse is responsible for using their knowledge and skills to effectively intervene. • Assessment o Clients who have an upper airway obstruction will not be able to speak or to breathe. The client will turn cyanotic and collapse. o Death can occur as soon as 4-5 minutes. ▪ In this case the client has an ineffective airway clearance. • Intervention o Conscious Client ▪ Five back blows between shoulder blades with heel of the hand ▪ Five abdominal thrusts (Heimlich maneuver) ▪ Alternate until blockage is dislodged o Unconscious Client ▪ Begin CPR ▪ Remove the object if it becomes visible o Airway Intubation ▪ Initiate an airway via an endotracheal tube or tracheostomy and suction as needed. Activating the Rapid Response Team – Cardiac & Respiratory Arrest • The purpose of the Rapid Response Team (RRT) is to bring critical care expertise to the client's bedside (or wherever it's needed). o RRT responds to non-ICU adult clients who are demonstrating signs of imminent clinical deterioration o Their goal is to prevent intensive care unit transfer, cardiac arrest or death o RRT members usually include: a hospitalist or critical care physician, critical care nurses, the bedside nurse, IV team (if applicable) and respiratory therapist: ▪ Bedside nurse: identifies the client at risk and activates the RRT, informing RRT of the client assessment ▪ ICU nurses: bring code cart, place leads, monitor cardiac activity, assist with implementation of orders (including administration of medications) and document the event ▪ Physician: leads the team ▪ Respiratory therapist: performs client assessment, provides ventilator support and airway management, and monitors pulse oximetry ▪ Other staff involved may include the charge nurse, unit secretary, manager of hospital operations and residents • Suggested criteria for activating the RRT: o Respirations: < 8 per min or > 28 per min, difficulty breathing o Heart rate: < 40 per min or > 140 per minute o Systolic blood pressure: < 90 mm Hg or > 180 mm Hg ▪ Neurogenic shock = decrease in BP o Acute neurologic change, e.g., acute loss of consciousness, new onset lethargy, sudden loss of movement or change in speech or vision o Staff member has significant concern about the client's condition o U/O < 50 mL over 4 hours o Oxygen saturation less than 90% despite supplementation • Other potential criteria: o Chest pain unresponsive to nitroglycerin o Seizure (unexpected) o Acute significant bleeding Myocardial Infarction (MI) – Cardiac and Respiratory Arrest A myocardial infarction is the irreversible death (necrosis) of heart muscle caused by a prolonged lack of oxygen supply (ischemia). • Assessment Findings o The clinical picture of an MI can vary. Clients will often complain of chest pain that is severe, crushing and is unrelieved by rest. o Pain may radiate to one or both arms, jaw, neck and back. o Women tend to present with atypical symptoms such as fatigue or shortness of breath. Other symptoms include: ▪ Nausea, vomiting and indigestion ▪ Apprehension, restlessness and fear ▪ Pulmonary edema ▪ Shock ▪ Oliguria ▪ Low grade fever • Diagnostic Findings o An ECG can show dysrhythmias, heart blocks or asystole (ST segment elevation, T wave inversion and Q wave formation). o The white blood cells (WBC) will show leukocytosis within the first two days and the erythrocyte sedimentation rate (ESR) will be elevated. o Creatine kinase (CK-MB) will be elevated after an MI and the lactate dehydrogenase (LDH), troponin (2-4 hours after MI) and myoglobin will rise as well. • Nursing Interventions o Provide thrombolytic therapy as ordered. It is important to dissolve the thrombus in the coronary artery within six hours of onset. o Communicate with client and family to relieve stress and anxiety. o Monitor vital signs, pain status, lung sounds, level of consciousness (LOC), ECG and pulse oxygenation. o Monitor intake, output and IV infusion. Make sure there is an open catheter available for emergency medications. o Administer medications as ordered (beta blockers, morphine, dysrhythmics and anticoagulant medications). Administer oxygen as ordered. o Prevent complications such as dysrhythmias, shock, congestive heart failure, rupture of heart muscle, pulmonary embolism and additional MI. Shock Shock is a clinical syndrome marked by inadequate tissue perfusion and oxygenation of cells, tissues and organs. Shock Information Homeostatic regulation means all body systems are working together to maintain a stable internal environment. If one or more of the components of homeostasis is malfunctioning, shock may follow. These components include: • Adequate cardiac output • Uncompromised vascular system • Adequate blood volume • Ability of tissue to extract and use oxygen Types of Shock • Cardiogenic shock (pump failure or heart failure) o may be seen if client has a myocardial infarction, dysrhythmias or pump failure. • Neurogenic shock o is a neural-induced loss of vascular tone (anesthesia, pain, insulin shock and spinal cord injury). o It can also be a chemically-induced loss of vascular tone (toxic shock, anaphylaxis, and capillary leak-burns). o Decrease in BP • Hypovolemic shock o is a loss of fluid from circulation. o A number of different conditions can cause hypovolemic shock, including: ▪ Hemorrhagic shock ▪ Cutaneous shock (burns) ▪ Diabetic ketoacidosis ▪ Gastrointestinal obstruction ▪ Diabetes insipidus ▪ Excessive use of diuretics ▪ Internal sequestration such as fractures, hemothorax or ascites Assessment • Clients in shock will present with cool, clammy skin, cyanosis and a decreased capillary refill. • They will be restless, weak and anxious. • Additionally, they will exhibit: o Tachycardia, decreased BP and weak or absent pulse o Metabolic acidosis o Oliguria and increased urine specific gravity o Shallow and rapid respiration Nursing Interventions • The nurse must maintain an adequate oxygen supply and patent airway, increase tissue perfusion, maintain systolic blood pressure greater than 90 mm Hg and treat acidosis. • A Foley catheter will be placed and hourly outputs will be recorded. • Tests for arterial blood gases (ABG) and central venous pressure (CVP) will be ordered and completed as well. • Keep the client warm and administer blood products and/or other fluids as ordered. • Make note that large amounts of fluids may be needed until the blood pressure increases and urine output increases. • Medications such as antibiotics (infection), vasoconstrictors (improve myocardial contractility), adrenergics (restore blood pressure) or steroids (septic shock) may be ordered. Trauma Care Trauma care is the nurse's ability to care for a client in a state of emergency and handle urgent situations where the cause of injury or disease isn't yet known. Trauma care nurses can work in hospital emergency rooms and other chaotic environments, and often need to coordinate care with doctors, other nurses and family members. • Airway o Airway with simultaneous cervical spine immobilization: ▪ Move the head to neutral position, but do not force if you encounter resistance ▪ Establish cervical spine immobilization using a rigid cervical collar (trauma clients are always presumed to have cervical spine injury) ▪ To open the airway, you must use the jaw thrust method – do not use head-tilt chin-lift! • Breathing o Breathing (look, listen and feel): ▪ Assess for spontaneous breathing, rise and fall of the chest, rate and pattern of breathing and use of accessory muscles ▪ Assess skin color and the integrity of soft tissues and bony structures of the chest wall ▪ Auscultate the lungs bilaterally ▪ Follow basic life support (BLS) procedures • Circulation ▪ Use an advanced airway device, e.g., endotracheal tube, with traumatized airway, emesis ▪ Inspect for tracheal deviation and jugular venous distention o Assess pulses: ▪ Palpate a central pulse (carotid, femoral or brachial in infants under one year of age) ▪ Assess for strength (normal, weak or strong) and rate (normal, slow or fast) o Blood pressure (BP): ▪ There is no evidence to support the following widely held assumptions – if a client has a palpable radial pulse, systolic blood pressure is estimated to be at least 80 mm Hg and a palpable femoral pulse is estimated at 70 mm Hg. If only the carotid pulse can be palpated, the BP is estimated at 60 mm Hg. ▪ Taking a formal BP can be deferred until later. o Inspect the client for any obvious signs of uncontrolled external bleeding. ▪ Apply direct pressure and elevate the area with gross hemorrhage. o If pulses are absent, life support measures should be initiated. Prepare and assist with an emergency thoracotomy (only in facilities with the resources to manage post-thoracotomy clients). ▪ After initial assessment, start two large-bore IVs: • Administer warmed isotonic crystalloid solution at a rate appropriate for the client's condition ▪ Interosseous needles may be used to access in the sternum, legs, arms or pelvis if the client's injuries/wound does not interfere with the procedure • Disability/Neurological Status o Assess pupils for size, shape, equality and reaction to light o Determine the presence of lateralizing signs – unilateral deterioration in motor movements, along with unequal pupils and other symptoms help locate the area of injury in the brain o Ability to move extremities, check for sensation o Ability to move against resistance o Score the client's level of consciousness on the Glasgow Coma Scale (even though it is not a measure of total neurological function) – initial and serial scores provide the trauma team with a good indication as to client outcomes • Expose/Examine o Undress the client carefully and quickly so injuries can be determined o Inspect for injuries or deformities • Vital Signs o Take a full set of vital signs, including: ▪ Pulse – > 120 BPM is of concern ▪ Respiratory rate – > 30 breaths per minute is of concern ▪ Blood pressure – < 100 mm Hg systolic is of concern o Focused adjuncts: ▪ ECG and pulse oximeter ▪ Insert an indwelling catheter and nasogastric tube if needed ▪ Maintain warmth – warm blankets, warming lights ▪ Facilitate radiographic and diagnostic studies, including chest X-rays, computed tomography (CT) scan of head, abdomen and chest, cervical spine X-rays and diagnostic peritoneal lavage if needed ▪ Blood typing, complete blood count and electrolytes ▪ Administer tetanus booster • Give Comfort/Pain Management o Pharmacological and non-pharmacological pain management as needed by conscious or unconscious client: ▪ Unmanaged pain can cause: • increased heart rate • increased force of cardiac contraction • increase in blood pressure • myocardial oxygen consumption • tachypnea • peripheral vasoconstriction • pallor • nausea • vomiting • muscle tension • Interview/History o Discover as much detail as possible about how the injury occurred (mechanism of injury): ▪ What was the mechanism of injury and specific injury patterns ▪ Type of motor vehicle, impact of injury and length of time since injury ▪ Injuries sustained – ask pre-hospital personnel about client's general condition, level of consciousness and apparent injuries ▪ Measure vital signs ▪ If the client is responsive, ask questions to evaluate the client's condition, pain, location, duration and intensity ▪ Obtain medical history, including age, any pre-existing medical conditions, allergies, last tetanus shot, previous hospitalization/surgeries, use of drugs/alcohol, date of last menstrual period and current medications • Inspect the Posterior Surfaces o When inspecting the client's posterior, maintain cervical spine protection, support extremities with suspected injuries and log roll your client onto the uninjured side. o Inspect their back, flanks, buttocks and posterior thighs o Palpate vertebral column and all posterior surfaces for deformity and tenderness. • Perform a Head-to-Toe – Full Body System Assessment o Note the general appearance including body position, guarding, stiffness or flaccidity of muscles. o Note any unusual odors, such as gasoline, chemicals, vomit, alcohol or urine/feces. o Head & Face ▪ Eyes – visual acuity (hold up fingers), inspect for periorbital ecchymosis (racoon eyes) and verify that pupils are equal and reactive to light and accommodation (perform PEARLA) ▪ Ears – inspect ecchymosis behind the ear (Battle's sign – late sign of head injury) and note any unusual drainage ▪ Nose – inspect any unusual drainage such as blood or clear fluid (may be cerebrospinal fluid if clear – do NOT insert a gastric tube through the nose) ▪ Neck – inspect for any trauma and position of the trachea and palpate for subcutaneous emphysema o Chest ▪ Observe the client's breathing, rate, depth and use of accessory muscles. ▪ Auscultate lungs and heart tones and palpate sternum and ribs for bony crepitus and deformities. o Abdomen ▪ Inspect for lacerations, abrasions, contusions, puncture wounds, impaled objects, ecchymosis and edema. ▪ Auscultate for bowel sounds ▪ Palpate gently for rigidity, guarding, masses and areas of tenderness. o Pelvis/Perineum ▪ Inspect for lacerations, abrasions, contusions, avulsions, puncture wounds, impaled objects, ecchymosis and edema. ▪ Palpate for instability and tenderness over the iliac crests and symphysis pubis. ▪ Inspect for blood at the urethral meatus, inspect penis for priapism. o Extremities ▪ Inspect color, assess skin temperature and moistness, and palpate pulses (comparing one side with the other). ▪ If the client has soft tissue injuries, inspect for bleeding, lacerations, abrasions, contusions, avulsions, puncture wounds, impaled objects, edema, angulation, deformity or open wounds. ▪ If the client has a bony injury, note crepitus, palpate for deformity and areas of tenderness. ▪ Assess the client's motor function by inspecting for spontaneous movement of extremities and determining the strength and range of motion of all four extremities. ▪ Check sensation by determining the client's ability to sense touch in all extremities. Nursing Interventions – Trauma Care ▪ Remove any pain producing objects, e.g., shattered glass ▪ Administer the prescribed medication and monitor for side effects of the medication, including respiratory depression, hypotension, nausea, vomiting, bradycardia and hallucinations ▪ Consider alternative methods, e.g., therapeutic touch, positioning/splinting, application of heat/cold, distraction, relaxation exercises and guided imagery ▪ Assess the family's desires and needs and call on a health care professional to provide explanations of what is occurring ▪ Utilize resources such as a social worker or chaplain [Show More]

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