TABLE 7 - 46 Nursing Care of the Adult in Medical and Surgical Emergencies


Condition
Assessment: Signs and Symptoms
Prehospitalization Nursing Care
In-hospital Nursing Care
Cardiovascular Emergencies
Myocardial infarction-ischemia and necrosis of cardiacmuscle secondary to insufficient or obstructed coronary blood flow
Prehospital:
Chest pain: viselike choking, unrelieved by rest or nitroglycerin
Skin: ashen, cold, clammy
Vital signs: pulse - rapid, weak, thready; increased rate and depth of respirations; dyspnea
Behavior: restless, anxious
In hospital:
C/V: blood pressure and pulse pressure decreased
Heart sounds: soft; Sj may be present
Respirations: fine basilar crackles
Lab: ECG consistent with tissue necrosis (Q waves) and injury (ST - segment elevation); serum enzymes elevated
  1. If coronary suspected, call physician, paramedic service, or emergency ambulance
  2. Calm and reassure patient that help is coming
  3. Place in semi-Powler's position
  4. Keep patient warm but not
  1. Rapidly assess hemodynamic and respiratory status
  2. Start I V as ordered - usually 5% D/W per microdrip to establish lifeline for emergency drug treatment
  3. Draw blood for electrolytes, enzymes, as ordered
  4. Place on cardiac monitor
  5. Relieve pain - morphine SO, I V as needed
  6. Take 12 - lead ECG Once patient is stable, transfer to CCU
Cardiac arrest - cardiac standstill or ventricular fibrillation secondary to rapid administration or overdose of anesthetics or narcotic drugs, obstruction of the respiratory tract (mucus, vomitus, foreign body), acute anxiety, cardiac disease, dehydration, shock, electric shock, or emboli
Cyanosis, gasping
Respirations: rapid, shallow, absent
Pulse: weak, thready, >120 beats/min, absent
Muscle twitching
Pupils: dilated
Skin: cold, clammy
Loss of consciousness
 CPR
  1. Position: flat on back
  2. Shake vigorously - establish unresponsiveness
  3. Call for help
  4. Tilt head back (chin lift)
  5. Check for breathing - listen at mouth, look at chest, feel with cheek
No breathing:
  1. Kneel close to head; place hand on forehead, bringing lower jaw forward and opening airway
  2. Pinch nostrils shut and blow two full breaths into patient's mouth
  3. Lips must form airtight seal
  4. Watch chest for adequate expansion; clear throat if indicated
  5. Check pulse - if present, breathe into mouth every 5 sec
  1. If monitored, note rhythm; call for help and note time
  2. Countershock if rhythm is ventricular fibrillation or ventricular tachycardia
  3. If countershock unsuccessful, begin CPR, as in prehospital care