Condition	Assessment: Signs and Symptoms	Prehospitalization Nursing Care	In-hospital Nursing Care
		No heartbeat: One- or two-person lay rescuers CPR: 80 chest compressions per minute, with two rescue breaths between every 15 compressions (no or two persons); with EMS responders 5 compressions Check pulse at neck after 1 thereafter Check pupils to determine effectiveness of CPR - should begin to constrict Provide early defibrillation with Automated External Defibrillator (AED) within 5 min of arrest if indicated If heartbeat returns: assist respiration and monitor pulse; continue CPR until help arrives	Two-person rescue First person: begins CPR as described in prehospital care Second person: Brings defibrillator to bedside and countershocks, if indicated by rhythm; defibrillate within 3 min of arrest if indicated Brings emergency cart to bedside Suctions airway, if indicated Bags patient with 100% O, arrest team arrives 7. Establishes intravenous line if one is not available
Shock - cellular hypoxia and impairment of cellular function secondary to: trauma, hemorrhage, fright, dehydration, cardiac insufficiency, allergic reactions, septicemia, impairment of nervous system, poisons	Early shock Sensorium: conscious, apprehensive, and restless; some slurring of speech light Pulse: rate <140/min; amplitude full to mildy decreased Blood pressure: normal to slightly decreased Neck veins: normal to slightly be full in septic shock or grossly distended in cardiogenic shock Skin: cool, clammy, pale Respirations: rapid, shallow GI: nausea, vomiting, thirst Renal: urine output 20-40 mL/hr	Check breathing - clear airway if necessary; if no breathing, give artificial respirations; if breathing is irregular or labored, raise head and shoulders Control bleeding by placing pressure on the wound or at pressure points (proximal artery) Make comfortable and reassure Cover lightly to prevent heat loss, but do not bundle up If neck or spine injury is suspected - do not move, unless victim in danger of wounds of more injury If patient unconscious or has wounds of the lower face B and jaw - place on side to promote drainage of fluids; position patient on back unless otherwise indicated	Check vital signs rapidly - pulse, pupils, respirations Check airway; clear if necessary; Po₂ should be maintained above 60 mm Hg; elevated Pco₂ indicates need for intubation and ventilatory assistance Control gross bleeding Prepare for insertion of intravenous line and central lines - if abdominal injuries present Peripheral line should be placed in upper extremity if fluids being lost in abdomen Draw blood for specimens: Hgb, Het, CBC, glucose, CO₂, sodium amylase, BUN, K⁺; type and crossmatch, blood gases, enzymes, prothrombin times Prepare infusion of 5% D/NS unless hypernatremia suspected; dextran if blood loss

Condition

Assessment: Signs and Symptoms

Prehospitalization Nursing Care

In-hospital Nursing Care

No heartbeat:

One- or two-person lay rescuers CPR:

80 chest compressions per minute, with two rescue breaths between every 15 compressions (no or two persons); with EMS responders 5 compressions

Check pulse at neck after 1 thereafter

Check pupils to determine effectiveness of CPR - should begin to constrict

Provide early defibrillation

with Automated External Defibrillator (AED) within

5 min of arrest if indicated

If heartbeat returns:

assist respiration and monitor pulse; continue CPR until help arrives

Two-person rescue

First person:

begins CPR as described in prehospital care

Second person:

Brings defibrillator to bedside and countershocks, if indicated by rhythm; defibrillate within 3 min of arrest if indicated
Brings emergency cart to bedside
Suctions airway, if indicated
Bags patient with 100% O, arrest team arrives

7. Establishes intravenous line if one is not available

Shock

- cellular hypoxia and impairment of cellular function secondary to: trauma, hemorrhage, fright, dehydration, cardiac insufficiency, allergic reactions, septicemia, impairment of nervous system, poisons

Early shock

Sensorium:

conscious, apprehensive, and restless; some slurring of speech light

Pulse:

rate <140/min; amplitude full to mildy decreased

Blood pressure:

normal to slightly decreased

Neck veins:

normal to slightly be full in septic shock or grossly distended in cardiogenic shock

Skin:

cool, clammy, pale

Respirations:

rapid, shallow

GI:

nausea, vomiting, thirst

Renal:

urine output 20-40

mL/hr

Check breathing - clear airway if necessary; if no breathing, give artificial respirations; if breathing is irregular or labored, raise head and shoulders
Control bleeding by placing pressure on the wound or at pressure points (proximal artery)
Make comfortable and reassure
Cover lightly to prevent heat loss, but do not bundle up
If neck or spine injury is suspected - do not move, unless victim in danger of wounds of more injury

If patient unconscious or has wounds of the lower face B and jaw - place on side to promote drainage of fluids; position patient on back unless otherwise indicated

Check vital signs rapidly - pulse, pupils, respirations
Check airway; clear if necessary; Po₂ should be maintained above 60 mm Hg; elevated Pco₂ indicates need for intubation and ventilatory assistance
Control gross bleeding
Prepare for insertion of intravenous line and central lines - if abdominal injuries present
Peripheral line should be placed in upper extremity if fluids being lost in abdomen

Draw blood for specimens: Hgb, Het, CBC, glucose, CO₂, sodium amylase, BUN, K⁺; type and crossmatch, blood gases, enzymes, prothrombin times
Prepare infusion of 5% D/NS unless hypernatremia suspected; dextran if blood loss