<NCLEX-RN GUIDE> - Emergency
 


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Emergency

  1. Cardiac Arrest
    1. CPR (illustration 1  illustration 2)
      1. Determine unresponsiveness
        1. shake and shout "are you okay?"
        2. call for help
      2. Position the client, if no evidence of trauma (if trauma, see section III of this lesson)
      3. Open the airway
        1. head-tilt, chin lift
        2. jaw thrust (if spinal injury suspected)
      4. Assess for breathing: look, listen and feel
      5. Give rescue breaths
        1. assess if breaths go into lungs by chest movement
        2. if air does not go in, reposition airway (see #3 above)
        3. if air still does not go in, check for foreign body
          1. abdominal thrust (Heimlich manueuver) (illustration 1  illustration 2)
          2. do not proceed until airway and rescue breathing established
        4. when airway is clear, check for abscence of pulse
        5. begin chest compressions
          1. be sure client is on a firm surface
          2. hand position is critical
          3. for adult, 1.5 to 2 inch compression depth
          4. two rescuers, 80 to 100 compressions per minute
          5. one rescuer, 80 compressions per minute
        6. alternate compressions and breaths

                                                                                                        i.            one and two rescuers, 15 compressions to two breaths

        1. reassess cardiopulmonary status after one minute and every few minutes thereafter
    1. Early defibrillation
      1. In adults, the arrhythmia most correctable is ventricular fibrillationif treated promptly
      2. Before starting CPR for ventricular fibrillation, call for help
  1. Shock - see the discussion of shock in Lesson 8A: Cardiovascular, section V
  2. Trauma Care

    1. Airway with simultaneous cervical spine immobilization
      1. Must use jaw thrust
      2. Do not use head-tilt chin-lift: it could injure neck
    2. Breathing
      1. Look, listen and feel for respirations
      2. Follow CPR procedure
    3. Circulation
      1. Assess pulses
        1. carotid pulse: BP at least 60
        2. femoral pulse: BP at least 70
        3. radial pulse: BP at least 80
      2. Stop any active, visible bleeding
      3. After initial assessment, start large-bore IVs (illustration 1  illustration 2  illustration 3)
    4. Disability: brief neurological exam
      1. Level of consciousness
      2. Pupil response to light
      3. Ability to move extremities
      4. Ability to move against resistance
    5. Expose
      1. Undress client
      2. Inspect for injuries or deformities
    6. Fahrenheit
      1. Take temperature
      2. Maintain warmth
        1. warm blankets
        2. warming lights
    7. Get vitals
      1. Pulse
      2. Respiratory rate
      3. Blood pressure
    8. History and head-to-toe full assessment
      1. How did injury occur - mechanism of injury
      2. Client's medical history
      3. Full body system assessment
    9. Inspect the back
      1. Roll the client over - log roll with help
      2. Inspect for injuries or deformities

CPR

  • Early defibrillation is the key to successful resuscitation for many adults.
  • Continually reassess during CPR to see if the client regains a pulse or begins breathing. Reassess to see that the chest moves and pulses are palpable during CPR.

SHOCK

  • In shock, the first hour of treatment is most critical. Early detection is key.
  • There are different ways to categorize shock. Basically, shock presents three potential problems:
    1. Not enough fluid in the blood vessels (hypovolemia) OR
    2. Fluid has moved outside the vessels, so cannot be pumped to the organs (distributive) OR
    3. Heart cannot pump fluid that is present (cardiogenic)
    4. Shock and Temperature
  • In septic shock, the skin and body temperature may increase. In other shock states, body and skin temperature will decrease.

Shock and Heart Signs

  • Early stages of shock activate the sympathetic nervous system. So in early stages, the client will not always be hypotensive.
  • Bradycardia is a very late sign in shock.
  • Another late sign is cardiac arrhythmia (other than sinus tachycardia). Arrhythmias reflect less perfusionof the coronary arteries and myocarditis.
  • As the myocardium receives less perfusion, heart pumps less.
  • Because less blood perfuses the brain, level of consciousness drops.

Shock and Urinary Output

  • Average adult urinary output is 0.5 to 1.0 ml/kg/hr. Less than 35 ml/hour reflects decreased renal blood flow. Acute renal failurecan result.

Shock and Respiration

  • As blood flow to lungs decreases, less gas exchange will occur.
  • When tissues receive less oxygen, they produce more lactate and metabolic acidosis sets in. Metabolic acidosis increases risk of cardiac arrhythmias.
  • For a client in shock, body cells receive less oxygen and nutrients. Thus treatment aims at increasing both available oxygen and volume of blood in vessels (unless the heart has failed).
  • Medications can improve tone of blood vessels (inotropes) or treat the cause of shock (corticosteroids, antibiotics).
  • When treating a trauma client, you must quickly assess ABCs. After you know the client is breathing and has a pulse, vital signs can wait while you stop any bleeding and start other interventions (such as starting IVS). Don't rely only on the vital sign numbers.

Head and Spine Injury

  • If client has head injury, the most important assessment is level of consciousness; next is pupil response to light. Changes in vitals are very late sign.
  • With trauma clients, assume spine is injured until proven otherwise. While you open the airway, you must keep cervical spine immobile.

Blanch test
Cardiogenic shock
Cardiomyopathy
Colloid
Crystalloid
Cyanosis
Diabetic ketoacidosis
Diaphoresis
Distributive shock
Glycogen
Hypovolemia
Hypoxemia
Inotropic
Motility
Myocardial infarction
Sepsis
Specific gravity
Triage