BIOC33H3 Lecture Notes - Sorbitol, Telemetry, Circulatory Collapse

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25 Mar 2013
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Chapter 69: Emergency and Disaster Nursing
Most patients with life-threatening or potentially life-threatening problems arrive at the hospital through the
emergency department (ED).
Triage refers to the process of rapidly determining the acuity of the patient’s problem, and it represents one of
the most important assessment skills needed by the emergency nurse.
The triage process is based on the premise that patients who have a threat to life, vision, or limb should be
treated before other patients.
o A triage system categorizes patients so that the most critical ones are treated first.
o The Emergency Severity Index (ESI) is a 5-level triage system that incorporates concepts of
illness severity and resource utilization to determine who should be treated first.
After the initial assessment to determine the presence of actual or potential threats to life, appropriate
interventions are initiated for the patient’s condition.
The primary survey focuses on airway, breathing, circulation, and disability and serves to identify life-
threatening conditions so that appropriate interventions can be initiated.
If life-threatening conditions related to airway, breathing, circulation, and disability are identified
at any point during the primary survey, interventions are started immediately and before
proceeding to the next step of the survey.
Airway with cervical spine stabilization and/or immobilization:
Primary signs and symptoms in a patient with a compromised airway include dyspnea,
inability to vocalize, presence of foreign body in the airway, and trauma to the face or
Airway maintenance should progress rapidly from the least to the most invasive method
and includes opening the airway using the jaw-thrust maneuver, suctioning and/or
removal of foreign body, insertion of a nasopharyngeal or oropharyngeal airway, and
endotracheal intubation.
The cervical spine must be stabilized and/or immobilized in any patient with face, head,
or neck trauma and/or significant upper torso injuries.
Breathing alterations are caused by many conditions (e.g., fractured ribs, pneumothorax,
allergic reactions, pulmonary emboli, asthma) resulting in dyspnea, paradoxical or
asymmetric chest wall movement, decreased or absent breath sounds, cyanosis,
tachycardia, and hypotension.
High-flow oxygen (100%) via a non-rebreather mask should be administered and the
patient’s response monitored. Life-threatening conditions may require bag-valve-mask
ventilation with 100% oxygen and intubation.
A central pulse is checked because peripheral pulses may be absent as a result of direct
injury or vasoconstriction.
Skin is assessed for color, temperature, and moisture.
Altered mental status and delayed capillary refill are the most significant signs of shock.
Two large-bore IV catheters should be inserted and aggressive fluid resuscitation initiated
using normal saline or lactated Ringer’s solution.
The degree of disability is measured by the patient’s level of consciousness.
A simple mnemonic can be used: AVPU: A = alert, V = responsive to voice, P =
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Key Points
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
responsive to pain, and U = unresponsive.
The Glasgow Coma Scale is used to further assess the arousal aspect of the patient’s
Pupils are assessed for size, shape, response to light, and equality.
The secondary survey is a brief, systematic process that is aimed at identifying all injuries.
Exposure/environmental control. All trauma patients should have their clothes removed so that a
thorough physical assessment can be performed.
Full set of vital signs/five interventions/facilitate family presence:
A complete set of vital signs, including blood pressure, heart rate, respiratory rate, and
temperature, is obtained after the patient is exposed.
Five interventions: 1) ECG monitoring is initiated; 2) pulse oximetry is initiated; 3) an
indwelling catheter is inserted; 4) an orogastric or a nasogastric tube is inserted; 5) blood
for laboratory studies is collected.
Family presence: family members who wish to be present during invasive procedures
and resuscitation view themselves as active participants in the care process and their
presence should be supported.
Give comfort measures. Pain management strategies should include a combination of
pharmacologic and nonpharmacologic measures.
History and head-to-toe assessment:
A thorough history of the event, illness, injury is obtained from the patient, family, and
emergency personnel.
A thorough head-to-toe assessment is necessary.
Inspect the posterior surfaces. The trauma patient should be logrolled (while maintaining cervical
spine immobilization) to inspect the posterior surfaces.
All patients should be evaluated to determine their need for tetanus prophylaxis.
Ongoing patient monitoring and evaluation of interventions are critical and the nurse is responsible for
providing appropriate interventions and assessing the patient’s response.
Depending on the patient’s injuries and/or illness, the patient may be (1) transported for diagnostic tests such as
x-ray or CT scan; (2) admitted to a general unit, telemetry, or intensive care unit; or (3) transferred to
another facility.
The emergency nurse should recognize the importance of certain hospital rituals in preparing the bereaved to
grieve, such as collecting the belongings, arranging for an autopsy, viewing the body, and making mortuary
Many patients who die in the ED could potentially be a candidate for nonheart beating donation; certain
tissues and organs such as corneas, heart valves, skin, bone, and kidneys can be harvested from patients
after death.
Elderly people are at high risk for injury primarily from falls.
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Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
The three most common causes of falls in the elderly are generalized weakness, environmental hazards, and
orthostatic hypotension.
When assessing a patient who has experienced a fall, it is important to determine whether the physical findings
may have actually caused the fall or may be due to the fall itself.
Prolonged exposure to heat over hours or days leads to heat exhaustion, a clinical syndrome characterized
by fatigue, light-headedness, nausea, vomiting, diarrhea, and feelings of impending doom.
Tachypnea, hypotension, tachycardia, elevated body temperature, dilated pupils, mild confusion,
ashen color, and profuse diaphoresis are also present.
Hypotension and mild to severe temperature elevation (99.6º to 104º F [37.5º to 40º C]) are due to
Treatment begins with placement of the patient in a cool area and removal of constrictive clothing.
Oral fluid and electrolyte replacement is initiated unless the patient is nauseated; a 0.9% normal saline IV
solution is initiated when oral solutions are not tolerated.
A moist sheet placed over the patient decreases core temperature.
Heatstroke results from failure of the hypothalamic thermoregulatory processes.
Increased sweating, vasodilation, and increased respiratory rate deplete fluids and electrolytes, specifically
Eventually, sweat glands stop functioning, and core temperature increases (>104º F (40º C).
Altered mentation, absence of perspiration, and circulatory collapse can follow.
Cerebral edema and hemorrhage may occur as a result of direct thermal injury to the brain.
Treatment focuses on stabilizing the patient’s ABCs and rapidly reducing the temperature.
Various cooling methods include removal of clothing, covering with wet sheets, and placing the patient in front
of a large fan; immersion in an ice water bath; and administering cool fluids or lavaging with cool fluids.
Shivering increases core temperature, complicating cooling efforts, and is treated with IV chlorpromazine.
Aggressive temperature reduction should continue until core temperature reaches 102º F (38.9º C).
Patients are monitored for signs of rhabdomyolysis, myoglobinuria, and disseminated intravascular coagulation.
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