Emergency Nursing

- “fast”, “quick”, “rapid”- time is of essence

Emergency- any sudden illness or injury which is perceived by the significant others and/or patient as requiring immediate medical attention

Emergency Nursing

care given to situations needing immediate medical interventions

care of individuals of all ages with perceived or actual physical or emotional alterations of health that are undiagnosed or that require further interventions

It is episodic (at any time, not constant), primary (immediate, NO restorative or rehabilitative) and usually acute (patients are wheeled out after care is given)

Scope of Emergency Nursing

A- SsessmentD- iagnosisT- reatmentE- valuation (for as long as the patient is stable)

Principle of Emergency Medical Treatment

1. Communicating in CrisisPrinciple 1…’patients need to know that their feelings are accepted and acknowledged by the ER personnel Role of nurses…

1. Give verbal and nonverbal2. Inform patients (what and why is it to

be done)Physician’s responsibility- (1) obtain informed consent, (2) explains any invasive procedures to patient

3. Be aware of one’s own feelings (self-assessment)

4. Talk with patients5. Encourage patients to discuss

opinions (e.g. delivery of care)6. Help patients verbalize frustrations7. Offer realistic hope8. Be honest

2. Patient Assessment, Reporting and DocumentationPrinciple 2… ‘rapid, accurate initial patient assessment and precise reporting and documentation, whether in the pre-hospital or hospital settings are keys to effective patient care’

Role of nurses..1. Verify that the scene is safe and

secure2. Be an astute observer 3. Information gathered must be

communicated4. Record other pertinent information of

the patient5. Provide explanation for omissions of care

(for purposes of law suits). 6. Record detailed triage notes

Triage notes:How the patient was brought to the hospital (ambulatory,

brought by private vehicle, conscious)Interventions initiated by EMT-BasicsMedications given by the EMT-Paramedics (advanced cardiac life support) EMT-Intermediate

(performs basic life support and some interventions in advanced cardiac life support)

3. Patient and Family EducationPrinciple 3…’patient and family education is the responsibility of every ER nurse’Role of nurses…

1. Provide effective, individualized instruction re: home care

2. Identify learning needs3. Establish realistic goals4. Allow for learning time5. Evaluate the results6. Document the instruction

Other Basic Principles in Emergency care

1. Provide for basic survival needs and comfort2. Help survivors achieve restful and restorative

sleep3. Provide privacy4. Provide non-intrusive ordinary social contact5. Address immediate physical problem6. Assist in locating and verifying the personal

safety of separated loved ones and friends7. Help survivors take practical steps to resume

ordinary day to day life

Basic Legal Issues

A. Consent (permission to care) to treatment1. Expressed (verbal or/and writing)-freely and

voluntary given2. Implied-presumed consent3. Involuntary-patient refuses care and an

individual gives consent (e.g. SO)4. Informed-given provided that proper

explanation has been done3 Essential components of Informed Consent:

The physician must Describe the procedure to be

performed Explain the alternatives

available to the procedure Detail the risks of the

procedureWhen does an informed consent become valid?

Legal age – 18 Mentally stable Information communicated in the language

known to the consente

Emergency Doctrine (implied consent)

- Implies that the client would have consented to treatment if able, because the alternative would have been death or disability

- Provides and exemption to obtaining informed consent before a procedure is to be done

Consent Dilemmas

1. MinorsEmancipated minors (economically independent, married)

2. Refusal to consent based on religious convictionGeneral rule-patient can refuse care on the ground of religious convictionsExceptions- (1) social circumstances, (2) court order e.g child who needs blood transfusion of whom both parents are Jehova’s witness, the court must have the final say

3. Refusal of treatment leaving against medical advice

Patient self-determination Act (1991)- Provides hospitalized patients with the ability to decide

regarding their wishes for termination or continuation of life support

E.g. a. Durable Power of Attorney

Attorney-in-fact (could be SO)- Things to be done are the

ones specified in the document signed by a conscious patient

b. Living wills - a written

statement/document detailing the patient’s desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent.

c. Do not resuscitate order (DNR) - Legal document signed by

the patient and his physician, which states that the patient has terminal illness and does not wish to prolong life through resuscitative efforts

- Also called an advance directive

What are good Samaritan laws?- Laws which are passed in order to encourage

lay persons or all persons present in emergency situations without fear of liability with regard to care given

- E.g Broken ribs caused by inappropriate performance of CPR by a nursing student=good Samaritan laws cannot be invoked

- E.g patient has incurred bruises (as long as it is NOT a major complications=good Samaritan law can be invoked)

- Effect of help should not be graver than the condition of the patient

Patient Transfer IssuesEmergency Medical Treatment and Active Labor Act (EMTALA)

(Before) Consolidated Omnibus Budget Reconciliation Act (COBRA)

Laws governing patient with regarding to dumping or transferring to one hospital to another because of inability to pay

EMTALA Highlights1. All individuals2. To determine the existence of an emergency

medical condition, there must be: threat to life or limb, or severe pain, or active labor

- Duty to provide AMS (Appropriate Medical screening)- whether patient is on an emergency situation

3. Hospitalized with specialized capabilities must accept transfers if with capacity to treat

4. Transfers require: consent of patient accepting physician accepting facility appropriate vehicle appropriate equipment qualified personnel records must accompany the

patient

Principle of Confidentialitynot entitled to spread/share information to persons not directly involve to the care of patientExemptions:- Public interest is at stake- Criminal cases- Consent of patient to reveal

information- Sued for damages (content of

patient’s chart is the very thing in issue)* Case of support is not a criminal case.

More of legal issues…DocumentationReportable conditions –report crimes to appropriate agencies, conditions mandated by laws, doctors and nurses has equal responsibility Note: report the condition even if you don’t have consent from the doctorDischarge instructions- written and oralPhysical evidence and chain of custody

- Bullets- Blood specimens/blood samples

Note: patient should not be force to undergo blood examinations (forcing would mean assault); exemptions—principle of confidentiality

Organ donation-brain death has been pronounced by the doctor; signed a legal consent

Roles in Emergency Nursing1. Triage Nurse2. Telephone Advice Nurse3. Poison Control Specialist4. Transport Nurses5. Trauma Nurse Coordinator6. Pediatric ED Nurse7. Case Manager8. EMS Liason9. Nurse Practitioner

10. Clinical Nurse Specialist

General Responsibilities of Emergency Nurses1. Works in an area staffed and equipped for the

reception and treatment of persons with conditions requiring immediate medical care, serious illness and trauma

2. Efficiently do A-P-I-E

Responsibility During Death and Dying 1. Provide ample opportunity to the patient and family to be

together2. Allow presence of family members during resuscitation3. Provides religious support4. Communicate honestly about the patient’s condition5. Encourage viewing the body in instances of sudden death

or trauma6. Because preservation of legal evidence is often

important in sudden death, SO are advised beforehand of the various tubes and devices present.

7. Determine client’s wishes re: organ donation8. May provide a follow-up telephone call to SO not present

re: their questions or concerns9. Make referrals to support groups

Disaster NursingDisaster- any situation, natural or manmade that produces an immediate patient load greater than the normal ED can handle

Mass Casualty Incident- Any time an incident or disease occurs that

leaves many people ill or injured- Can be caused by natural ( i.e. earthquakes,

floods) or accidental or intentional disasters (terrorist attacks, sarin gas release)

Classification of MCI1. Level I- involves more than 100 patients2. Level II- involves greater than 50 but not

more than 100 patients3. Level III- greater than 25 but not more than

504. Level IV-greater than 10 but not more than

255. Level V-an incident involving no more than

10 patients6. MCI (contamination)

- an MCI of any level, which includes or has the potential for biological, chemical or radiological contamination

Note: Common on all levels:

-Having a great impact on the emergency department and going beyond the capacity to treat

Categories of Disaster:1. Class A (all require response by hospital disaster

team); bigger impact- Natural disasters: earthquakes, floods,

tornadoes - External disasters/medical emergencies:

chemical exposure, epidemic of disease, nuclear fall-out

2. Class B- Internal disasters/medical emergencies that

may require response by hospital disaster team or specially created crisis team

- Death of key personnel (pope, president), large scale poisoning, death of religious personnel

3. Class C

- Internal disasters/non-medical emergencies- May require response by hospital disaster team

or specially created crisis team- Bomb threats, strikes, criminal activity (rape,

kidnapping, shooting)

Phases /Stages of Disaster1. Pre-impact/preparedness

- Occurs prior to the onset of the disaster- Not all type of disasters has the pre-impact

phase2. Impact/response

- Disaster occurs, continuing to immediately following disaster (brief or lasing to few hours)

- Inventory and rescue period- Assessment of the extent of the losses,

planning on how to use the resources left and how to rescue the victims

3. Post-impact/recovery- Majority of rescue operations- Remedy and recovery period- Lengthy phase and may last for years

1. Honeymoon phase-feelings of euphoria2. Disillusionment-anger, disappointment3. Reconstruction phase-acceptance of loss,

coping stress, rebuilding

DISASTER PLAN A predefined set of instructions for a

community’s emergency responders Features of a good disaster plan

1. Written2. Well-publicized3. Realistic4. Rehearsed

Key components of Disaster Plan1. Patient care

System on how to receive and distribute patients whether incoming/evacuated patientsTriage procedureProvides care for the greatest number (NOT applicable in non-disaster triage) Avoid treating ambulatory patients as dependent patientsPre-assignment with regard to responsibillity

2. CommunicationInternal: within personnelExternal: one hospital facility to another

3. Resources-staffDisaster team must know how to contact the resource staff

4. Security/ Safety –ensure the scene is safe

5. Coordination with Public Agencies6. Documentation7. Public relations- officials8. Critical Incident Stress Debriefing

- NOT a form of psychotherapy

- Done to mitigate (lessen) the occurrences of PTSD

- Group process involving persons who are victims/ survivors of an overwhelming event or trauma including those who may have been impacted by the trauma

- Aims to prevent the subsequent development of PTSD

- Provides avenue for the patient to express feelings, coping mechanisms, lessons learned

Disaster Management Principles1. Prevent occurrence2. Minimize casualties3. Prevent further casualties4. Rescue the injured5. Provide first aid6. Evaluate the injury7. Provide definitive care8. Facilitate reconstruction and recovery

The responsibility of nursing care vary (depends on situation or available resources)May include triage, patient care, equipment, directing others, recording, transportation

What are the psychological and emotional responses to emergency and disaster?

Immediate reactions (anxiety, frustration, anger, physical symptoms)

Delayed reactions (feelings of loss, grief and guilt, flashbacks, nightmares)

Nursing Interventions:A. For immediate stress reaction

1. 5 minutes break at least every hour2. Monitor for shaking, trembling, loss of

coordination3. Provide rest area4. Rotate frontline personnel

B. For delayed reaction1. 2 mandatory debriefing sessions2. Encourage liberal leave policy3. Begin stress management class

Triage System - “trier” to sort

Triage Nursing- care given to patients to ensure that those requiring

immediate attention for life threatening emergencies receive it

- first used during Napoleonic war

Primary goal of an effective triage:- RAPID identification of patients with urgent, life

threatening conditions

Complementary goals of an effective triage:1. Prioritizing care needs for all patients2. Regulating patient flow through ED3. Determining the most appropriate area for

treatment- the ED or an outside primary care area

Note: The triage models in disaster

those patients who are severely injured and are unlikely to survive despite medical attention would receive the lowest priority triage.

(greatest good for the greatest number) The triage model in emergency nursing

Priority is those patients who are in severe condition

Triage Models

Triage tags – refers to color coding, identification to each injured patient; for priority, save time

A. Non-disaster Triage models -i.e. models for individual triage: traffic director; spot

check; comprehensive

Purpose: to provide best care for each individual patient.

A.1. Models for individual triage

a.1.1. Traffic director categories: emergent (life-threatening and

major illness) & non-urgent (treatment can be delayed)

sometimes done by unlicensed person assessment consist of chief complaints disadvantage : emergent patients are

disregards due to mixed with nonemergent patients

sort to acute care or waiting room no further evaluation by triage (re-triage) when used

1. low daily census2. no waiting period for patients to see

licensed health care professional

a.1.2. Spot Check categories: emergent (life threatening),

urgent (major illness), delayed (patient may be treated or treatment may be delayed for more than 20 hours)

assessment by RN or MD no planned reevaluation when used

1. high patient census2. waiting period is anticipated

a.1.3. Comprehensive Triage categories: life-saving (multiple trauma;

assessment is continuous); stable but urgent (sickle-cell, fractures; every 15 min); stable but non-urgent (small laceration; every 30 min); stable, may wait indefinitely for care (abrasion, impetigo; every 60 min)

assessment done by RN patients who remain in the waiting room

are re-assessed every 15-60min depending on severity of illness or injury

when used1. high patient census2. treatment space limited

B. Multi-casualty/Disaster Triage Model

Purposes: to provide the most effective care for the greatest number of patients

Sample models for Multi-casualty/disaster triage modelb.1.1. Simple

categories: immediate care (multiple traumas, inhalation injuries); delayed care (extremity fractures, minor burns)

b.1.2. Military 5 level triage system

Categories1. Immediate (I) triage tag: red life-threatening injuries that probably

survivable with immediate treatment i.e. tension pneumothorax,

respiratory distress, airway injuries, shock

2. Delayed (II) triage tag: yellow treatment may be postponed without

loss of life i.e. minor extremity fractures,

lacerations with hemorrhages controlled

3. Minimal triage tag: green little or no professional care required ambulatory, can self-treat or seek

alternative medical attention independently

i.e. minor lacerations, abrasions

4. Expectant (0) triage tag: black have lethal injuries and will die

despite treatment i.e. devastating head injuries,

destruction of all vital organs

5. No apparent injuries triage tag: white

b.1.3. Disaster ((4 level triage))* Categories

1. Emergent triage tag: red critical life threatening; patient is

expected to live; shock; airway problems

2. urgent triage tag: yellow major illness/injuries should be

treated within 20min – 2 hours; i.e. open fractures, chest wounds

3. non-urgent triage tag: green minor injuries, usually ambulatory;

are maybe delayed for more than 2 hours; i.e., closed fractures, sprains

4. Dead or with impending death – Triage tag: black slim to no chance of survival;

shouldn’t take priority over salvageable patient; i.e., massive trauma, extensive 3rd degree burns

Other Triage Models

1.) START ((simple triage and rapid treatment)) can be performed by lightly trained lay &

emergency personnel in emergencies physiologic parameters: RPM

R – respirationP – pulseM – mental

Categories:1. Priority (0)

tagged as black; patients not breathing and have no pulse

evacuation: leave where they fell attempt to open airway to assess

respiration and pulse

2. Priority (1) – immediate tagged as red; patients who have R - > 30 cpm P – absent radial pulse M – altered used in evacuation: by MEDEVAC or

ambulance

3. Priority (2) delayed

tagged as yellow R < 30 cpm P – have radial pulses present M – alert evacuation: delayed until all immediate

persons have been transported

4. Priority (3) – minor tagged as green walking wounded evacuation: not evacuated until all

immediate & delayed persons have been evacuated

2.) Advanced triage-similar to military- implemented by skilled nurses

* Categories:

1. Expectant (black)

severely injured with life threatening medical crisis unlikely to survive given with care available

should be taken to a holding area and given pain killers

cardiac arrest; septic shock not used in ER Advance cardiac life support

2. Immediate (red) immediate surgery, “cannot wait” but likely

to survive (i.e. tension pneumothorax)

3. Observation (yellow) stable for the moment but requires

watching and frequent re-triage (i.e. laceration with controlled hemorrhage)

4. Wait (green) walking wounded required doctors care in several hours or

days but not immediately, maybe told to go home and come back home within the next day

i.e. broken bones without compound fractures, soft tissue injuries

5. Dismiss (white) walking wounded with minor injury, do not

require doctor’s care i.e. small cuts, scrapes

STEPS IN TRIAGE1. Primary survey

consist of ABC consist of ABCD proposed by ENA

A – Airway B – BreathingC – CirculationD – Disability (neurologic assessment status)E – Exposure or environment (coldness or hotness)

AVPU (a very practical use)

A – alertV – voiceP – pain (response)U – unconscious/unresponsive

2. Secondary survey follows primary survey and is very brief use SAMPLE (S – signs and symptoms; A –

allergies; M – medications; P – pertinent past history; L – last oral intake, E – events leading to problem)

- AMPLE- a crash plan

A – airway/breathingC – cardiovascular

R – respiratoryA – abdominalS – spinalH – head & EENTP – pelvisL – legsA – arteries (pulses) N – nerves

- head to toe assessment : 90 seconds* Focused Assessment- diagnostic procedures

1. ECG2. lab studies3. radiology

CARDIOPULMONARY ARREST

- with patients heart, circulation, and respiration suddenly cease

Causes:a. Metabolic

a.1. hypoglycemiaa.2. hyperkalemia

b. Drug-inducedc. Pulmonaryd. Neurologice. Hypovolemicf. Other cardiac causes

a. Metabolic causesa.1. hypoglycemia

s/s: unconsciousness, tachydysrhythmias, seizures, aspiration, weaknessmgt: 50% dextrose

a.2. hyperkalemias/s: ECG (prolonged Q-T interval; peaked T wave; wide QRS complexesmgt: calcium chloride; sodium bicarbonate

P – atrial contractionQRS – ventricles contract to pump out bloodST – time when the ventricles end of contraction and beginning of the T waveT – time of repolarization

b. Drug- Inducedb.1. TCA’s (e.g. amitryptyline)

s/s: tachydsyrhythmias mgt: sodium bicarbonate – alkylating agent

b.2. Narcoticss/s: bradydysrhythmias; heart blocksmgt: naloxone (Narcan)

b.3. Propanolols/s: cardiac: bradydysrhythmias; respiratory: bronchospasm; metab: hypoglycemiamgt: for bradydysrhythmias: Isuprel,

Atropine for bronchospasm: aminophylline for hypoglycemia: 50%dextrose

c. Pulmonary c.1. asthma

s/s: severe bronchospasm, tachydysrhythmiasmgt: endotracheal intubation and ventilatory support

c.2 pulmonary emboluss/s: pleuritic chest pain, SOB, tachydsyrhythmiasmgt: good ventilatory support

c.3. Tension pneumothoraxs/s: distended neck veins, tracheal deviation, asymmetric chest expansionmgt: needle thoracotomy, chest tube

d. Neurogenicd.1. increased ICP from any causes

s/s: dilated pupils, decerebrate-decorticate posturing, dysrhythmiasmgt: steroids, diuretic agents, surgeryi.e Mannitol: MIO monitoring; soluset used, risk for cardiopulmonary edema

e. Hypovolemia e.1 anything that causes volume loss of blood

s/s: tachycardia, decreasing bp, cool clammy skinmgt: IV fluids, PASG (Pneumatic anti-shock garment), shock positionPASG is contraindicated in the ff:

Cardiopulmonary edema Severe chest injuries even

patient is in shock Pregnant woman: do not cuff

abdomenf. Other cardiac causes

f.1 Pericardial tamponades/s: distended neck veins, decrease BP, bradydysrhythmias, widening pulse pressuremgt: IV fluids, atropine, Isuprel, thoracotomy

Chain of survival

1. Early access2. Early CPR3. Early defibrillation4. Early advance care

Basic Life support

Survey the scene (Scene is safe, crowd controlled)

Introduce self

Activate the EMS (Emergency Medical Services)-Call the ambulance

Check for consciousnessL-ookL-istenF-eel

Hey, hey are you ok?

Give 2 initial breaths. Continue on LLF.

Check pulse. Brachial-infant; carotid-adult

If pulse and respiration is absent, do 30 cycles of chest compressions: 2 breaths

Wait for the automated external defibrillator

AED

Check if shockable Check if not shockable

Ventricular tachycardia, Asystole also called ventricular defibrillation ventricular stand still,

pulseless electrical activity (no blood to be pumped)

Deliver 1 shock using AED. Cannot perform defibrillation.

C-L-E-A-R.-Nobody is touching the patient. Repeat CPR for 5

-No metallic objects. cycles until ACLS -Not on wet ground. arrives.

Repeat CPR for 5 cycles

Shockable –refers to dysrhythmias which can be subjected to defibrillation (electrical activity of the heart is present

BLS can operate automated external defibrillator Ventricular tachycardia> 100 bpm

Nitroglycerine patches-dilates the vessel to encourage blood to stay in the venous system-less cardiac rateUse gloved hand in detaching the plastic to prevent headache.

It will burst due to the electrical activity being delivered

Position of patches: Anterolateral position-most common Anterior and posterior

Advanced Cardiac Life Support (ACLS)

Pulseless-no respiration

Deliver oxygen

Monitor using ECG 12 -leadAED

If shockable

Administer 1 shock (AED)

Repeat CPR for 5 cycles

If shockable

Wait AED

CPR (5 cycles)

AED (1 shock)

CPR (5 Cycles)

Administer Epinephrine (1 mg/IV) Vasopressin (40 IU IV)

- If epinephrine is not the choice

If not shockable Give CPR for 5 cycles

Administration of the ff:1. Epinephrine (1

mg/IV) 3-5 minutes2. Vasopressin 40 IU/IV3. Atropine 1 mg/IV in

3 doses

If shockable

CPR (5 cycles)

AED (1 shock)

CPR (5 Cycles)

Administer the ff

antiarrhythmic drugs Amiodarone Lidocaine Magnesium

If not shockable

Give CPR for 5 cycles

Administration of the ff:1. Epinephrine (1

mg/IV) 3-5 minutes2. Vasopressin 40 IU/IV3. Atropine 1 mg/IV in

3 doses

Difference between BLS and ACLS- administration of drugs0-4 min brain damage not likely4-6 min brain damage is probable6-10 min irreversible brain damage is possibleMore than 10 min irreversible brain damage is certain

Contraindication in Defibrillation

1. Less than 1 year old (infant’s heart is normal, therefore the electrical activity is normal)—respiratory problems brought about by Foreign A Body Obstruction and drowning are common causes among this age

2. If electrical activity is normal, no defibrillation should be given.

3. Patients with severe traumatic chest injuries4. Hypothermic-no to defibrillation, warm the patient first

before applying defibrillation

Cardioversion Synchronous electrical countershock timed to coincide

with the QRS Not delivered on the T (repolarization) wave

(compromised delivery of energy)

Differences:

Cardioversion Defibrillation

-set in synchronous mode-sedate patient if conscious-hemodynamically unstable

-set in unsynchronous mode-patient is hemodynamically stable

Nursing Responsibility for Cardioversion:1. Monitor V/S, LOC and cardiac rhythm frequently until

patient is hemodynamically stable and returns to pre-orientation LOC

Complications of Cardioversion: Asystole PVC’s (Premature ventricular contractions) Ventricular tachycardia Ventricular fibrillation Return to atrial fibrillation or atrial flutter

Drugs Commonly Used in Cardiopulmonary Resuscitation

Drugs Classifications

1. Adenosine (Adenocard)2. Atropine

3. Bretylium (bretylol)

4. Epinephrine (adrenalin)5. Isoproterenol (Isuprel)6. Lidocaine (xylocaine)7. Procainamide

(pronestyl)8. Sodium Bicarbonate

9. Verapamil (Calan, isoptin)

Antiarrhythmias

Anticholinergic; parasympathomimetic

Category 3 antidysrhythmias

Sympathomimetic drugs

Sympathomimetic drugs

Category 1B antidysrhythmias

Category 1A antidysrhythmias

Electrolyte , alkylating agent in metabolic

acidosis Calcium channel blocker,

category 4 antidysrhythmias

Commonly Used Parental Vasoactive Drug

Drugs Classifications

1. Esmolol (brevibloc)2. Calcium chloride3. Diazoxide

(hyperstat)4. Diltiazem (cardizem)5. Dobutamine

(dobutrex)6. Dopamine (Intropin,

Dopastat)

Antidysrhythmias, ACE inhibitors

Electrolytes Antihypertensive drug

Calcium channel blocker Sympathomimetic drugs Sympathomimetic drugs

Other Drugs in Cardiac Emergencies

Drugs Classifications

1. Enalapril (Vasotec)2. Labetalol

(Normodyne)3. Nitroglycerine

(Tridil)4. Nitroprusside

(Nipride)5. Norepinephrine

(levophed)6. Propanolol (Inderal)

ACE inhibitor

Alpha-adrenergic blocker Vasodilator

Vasodilator; antihypertensives

Vasopressor; adrenergic Beta blockers

Morphine sulfate: emergency drug of MI

-reduces the preload thus decreasing the myocardial oxygen demand; relieves pain

Phases of MI:

A. Ischemic phase- myocardial repolarization is altered and delayed causing the T wave to invert

B. Injury phase-causes ST segment changes-ST segment rises at least 1 mm measuring

0.08 seconds. If the myocardial injury is on the endocardial surface, the ST segment is depressed 1 mm or more at least 0.08 seconds

C. Infarction-abnormal Q wave is 0.04 seconds or longer(Smeltzer & Bare, 2004, p. 726)

shock

-state of inadequate perfusion and oxygenation to vital organs and tissues throughout the body

Vital Organs Affected by shock: Brain Heart Kidneys Liver

4 Stages of Shock:1. Initial –cellular level

- increase anaerobic metabolism; decrease aerobic metabolism

- Increase lactic acid production= pain- Decrease cardiac output

2. Compensatorya. Renin-angiotension systemb. Sympathetic

- Release epinephrine (vasoconstriction)c. Release of ADH (posterior pituitary gland)d. Intracellular fluid shifts

3. Progressive 4. Refractory (Irreversible)

Types of Shock:1. Hypovolemic shock

-caused by a decrease in circulating volume greater than 15 %-s/s: initial stage: pain, tachycardia, skin dry and

slightly moist, ABG’s normalCompensatory stage: anxious, hypotension,

cool, clammy skin, may have metabolic acidosis

Progressive: confused, restless, agitated, profound hypotension, cardiac dysrhythmias, skin pale, no purposeful movement

Irreversible: severe hypotension, tachypnea with shallow depth, profound metabolic acidosis, comatose

2. Cardiogenic- Caused by abnormal cardiac functioning or pump failure- s/s: restless, agitated, hypotension, tachycardia with weak thread pulse, decreased pulse pressure, skin cool and moist, JVD

3. Obstructive-results from the inability of the ventricles of the heart to fill or empty appropriately because of an obstruction in the blood flow from the heart-s/s: anxiety, hypotension, JVD, pallor, diminished or absent breath sounds, tracheal deviation

4. Distributivea. Anaphylactic shock-results from an overwhelming

immune response to the presence of an allergen or antigens/s: marked restlessness, difficulty swallowing or severe itching, hypotension tachycardia

b. Septic shock-associated with endotoxic release of gram negative bacteria in the blood streams/s: decreased BP, or normal BP with widened pulse pressure, tachycardia, hyperventilation, positive cultures

c. Neurogenic shock-occurs as a result of decreased sympathetic control of vasomotor responsess/s: hypotension, bradycardia followed by tachycardia, pallor, decreased to absent urinary output.

Emergency Care Steps For Shock:1. Maintain an open airway and assess respirate2. If with adequate breathing: apply high concentration

oxygen by nonrebreather mask.3. Assist ventilation or perform CPR if necessary4. Control bleeding5. Apply and inflate the PASG6. If with possibility of spine injury: elevate the legs 8-12

inches7. Splint any suspected bone injuries or joint injuries en route

to the hospital. If in shock, place the body on a spine board.

8. Prevent loss of body heat9. Transport patient immediately.10. If patient is conscious, speak calmly, and reassuringly

throughout the assessment, care and transportGeneral Treatment Measures of Shock:

1. Follow ABC guidelines2. Supine position with spinal alignment maintained3. Airway should be secured, protected and supplemental

oxygen should be initiated through the appropriate

delivery device dependent on the client’s overall assessment.

4. Initiate an IV access5. Initiate continuous cardiac and Sa O2 monitoring and

prepare doe frequent, repetitive vital sign assessments

6. Maintain stabilization of all deformities and prevent hypothermia

7. Place an indwelling cath8. Administer sympathomimetic drugs as ordered