EMERGENCY NURSING PROCEDURES

  1. Purpose - to initiate assessment and intervention procedures that will speed total care of the patient toward a successful outcome.
  2. Emergency nursing procedures for adults are detailed in Table 7-46.
  3. Legal issues

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 SO4 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 seconds
  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
   
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 minutes 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:
  1. Pages arrest team
  2. Brings defibrillator to bedside and countershocks, if indicated by rhythm; defibrillate within 3 minutes of arrest if indicated
  3. Brings emergency cart to bedside
  4. Suctions airway, if indicated
  5. Bags patient with 100% O2 arrest team arrives
  6. Assists with intubation when 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
  1. Check breathing - clear airway if necessary; if no breathing, give artificial respirations; if breathing is irregular or labored, raise head and shoulders
  2. Control bleeding by placing pressure on the wound or at pressure points (proximal artery)
  3. Make comfortable and reassure
  4. Cover lightly to prevent heat loss, but do not bundle up
  5. 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
  1. Check vital signs rapidly - pulse, pupils, respirations
  2. Check airway; clear if necessary; Po2 should be maintained above 60 mm Hg; elevated Pco2 indicates need for intubation and ventilatory assistance
  3. Control gross bleeding
  4. Prepare for insertion of intravenous line and central lines - if abdominal injuries present
  5. Peripheral line should be placed in upper extremity if fluids being lost in abdomen
  1. Draw blood for specimens: Hgb, Het, CBC, glucose, CO2, sodium amylase, BUN, K+; type and crossmatch, blood gases, enzymes, prothrombin times
  2. Prepare infusion of 5% D/NS unless hypernatremia suspected; dextran if blood loss
 
Severe or late shock
Sensorium:
confused, disoriented, apathetic, unresponsive; slow, slurred speech, often incoherent
Pupils:
dilating, dilated, slow or nonreactive to light
Pulse:
rate >150 beats/min, thready, weak
Blood pressure:
80 mm Hg or unobtainable
Neck veins:
flat in a supine position - no filling; full to distended inseptic
or
cardiogenic shock
Skin:
cold, clammy, mottled; circumoral cyanosis, dusky, cyanotic
Eyes:
sunken - vacant expression
Renal:
urine output <20 mL/hr
  1. Raise feet 6-8 inches unless patient has head or chest injuries; if victim becomes less comfortable, lower feet
  2. If patient complains of thirst, do not give fluids unless you are more than 6 hour away from professional medical help; under no conditions give water to patients who are unconscious, having seizures or vomiting, appearing to need general anesthetic, or with a stomach, chest, or skull injury
  3. Be calm and confident; reassure patient help is on the way
  1. Assess and intervene as for early shock; then obtain information as to onset and past history
  2. Catheterize and monitor patient urine output as ordered
  3. Take 12-lead ECG
  4. Insert nasogastric tube and assess aspirate for volume, color, and blood; save specimen if poison or drug overdose suspected
  5. If CVP low - infuse 200-300 mL over 5-10 min
    If CVP rises sharply, fluid restriction necessary; if remains low, hypovolemia present
  6. If patient febrile - blood cultures and wound cultures will be ordered
  7. if urine output scanty or absent - give mannitol as ordered
Respiratory Emergencies
  
Choking - obstruction of airway secondary to aspiration of a foreign object
Gasping, wheezing; looks panicky, but can still breathe, talk, cough
Cough: weak, ineffective; breathing sounds like high-pitched crowing; color - white, gray, blue
Difficulty speaking; clutches throat
Do not interfere if coughing; do not slap on back; watch closely; call for assistance
Victim standing, sitting and conscious:
Perform
obstructive airway maneuver
(formally Heimlich maneuver), stand behind victim, wrap arms around waist, place fist against abdomen, and with your other hand, press it into the victim’s abdomen with a quick upward thrust until the obstruction is relieved or the victim becomes unconscious
As in prehospital care
   
Victim lying down:
Roll the victim onto his or her back; straddle the victim’s thighs; place heel of hand in the middle of abdomen; place other hand on top of the first; stiffen arms and deliver 6-10 abdominal thrusts
As in prehospital care
Unconscious victim:
Lay rescuers - proceed to CPR. No abdominal thrusts or blind finger sweeps
EMS responders Try to ventilate; if unsuccessful, deliver abdominal thrusts using technique described for obstructive airway; probe mouth for foreign object;
keep repeating above procedure until ventilation occurs; as victim becomes more deprived of air, muscles will relax and maneuvers that were previously unsuccessful will begin to work; when successful in removing obstruction, give two breaths; check pulse; start CPR if indicated
On obese or pregnant victims - use chest thrusts instead of abdominal thrusts
You are victim and alone: Place your two fists for abdominal thrusts; bend over back of chair, sink, etc. and exert hard, repeated pressure on abdomen to force object up; push fingers down your throat to encourage regurgitation
As in prehospital care; when probing mouth for foreign object, turn head to side, unless patient has neck injury, in event of neck injury, raise the arm opposite you and roll the head and shoulders as a unit, so that head ends up supported on the arm
Acute respiratory failure - sudden onset of an abnormally low Pao2 (<60 mm Hg) or high Pco2 (>60 mm Hg) secondary to: lung disease or trauma, peripheral or central nervous system depression, cardiac failure, severe obesity, airway obstruction, environmental abnormality
Hypoxia
Sensorium: acute apprehension
Respiration: dyspnea; shallow, rapid respirations
Skin: circumoral cyanosis; pale, dusky skin and nailbeds
C/V: slight hypertension and tachycardia, or hypotension and bradycardia
Hypercapnia
Sensorium: decreasing mentation; headache
Skin: flushed, warm, moist
C/V: hypertension; tachycardia
If you suspect respiratory distress, call physician; calm and reassure patient place position; keep warm but not hot; phone for ambulance; if respirations cease or patient becomes unconscious, clear airway and commence respiratory resuscitation; check pulse: initiate CPR if necessary, continue resuscitation until help arrives
Check patient’s ability to speak; maintain airway by placing in E high Fowler’s position; check vital signs: BP, pulse rate and rhythm, temperature, skin color, rate and depth of respirations
Prepare for intubation if:
  1. Patient has flail chest
  2. Patient is comatose without gag reflex
  3. Has respiratory arrest; maintain mouth to mouth until intubation
  1. PaCO2 > 55 mm Hg
  2. PaO2 < 60 mm Hg
  3. F1O2 > 50% using nasal cannula, catheter, or mask
  4. Respiratory rate > 36
After intubation:
  1. Check bilateral lung sounds
  2. Observe for symmetrical lung expansion
  1. Maintain humidified oxygen at lowest F1O2possible to achieve PaO2 of 60 mm Hg
       
 
Improve ventilation (decrease Pco2) by:
  1. Liquefying secretions - oral and parenteral fluids; if intubated, frequent instillations of normal saline or sodium bicarbonate
  2. Frequent suctioning
  3. IPPB indicated if tidal volume decreases
  4. Chest physiotherapy Administer drugs as ordered: sympathomimetics, xanthines, antibiotics, and steroids
Monitor: arterial blood gases, electrolytes, Het, Hgb, and WBC
Do not:
  1. Administer sedatives
  2. Correct acid-base problems without monitoring electrolytes
  3. Overcorrect PaCO2,
  4. Leave patient alone while oxygen therapy is initiated
Once patient is stable, transfer to ICU
Near-drowning-asphyxiation or partial asphyxiation due to immersion or submersion in a fluid or liquid medium
Conscious victim:
Acute anxiety, panic; increased rate of respirations
Pale, dusky skin
Unconscious victim:
Shallow or no respirations
Weak or no pulse
Conscious victim:
  1. Try to talk victim out of panic so can find footing and way to shore
  2. Utilize devices such as poles, rings, clothing to extend to victim; do not let panicked victim grab you; do not attempt swimming rescue unless specially
  3. If you suspect head or neck injury - handle carefully, floating victim back to shore with body and head as straight as possible; do not turn head or bend back
Unconscious victim:
  1. If victim not breathing: as soon as you have firm support begin mouth-tomouth resuscitation
  2. Tilt head back, bring jaw forward, pinch nostril shut, give two quick breaths
Non-symptomatic near-drowning victim:
  1. Draw blood for arterial blood gases with patient breathing room air
  2. PA and lateral chest x-ray
  3. Auscultate lungs
  4. Admit to hospital for further evaluation if.
    1. PaO2 < 80 mm Hg
    2. pH < 7.35
    1. Pulmonary infiltrates present, or auscultation reveals crackles
    2. Victim inhaled fluids containing: choline, hydrocarbons, sewage, or hypotonic or fresh water
 
On shore:
  1. Check breathing
  2. Lay victim flat on back; cover and keep warm
  3. Calm and reassure victim
  4. Do not give food or
  5. Get to medical assistance as soon as possible
  6. If unconscious and not breathing: begin sequence for CPR; compress water from abdomen only if interfering with ventilation
  7. If airway obstructed: reposition head; attempt to ventilate; if EMS responder: perform 6-10 abdominal thrusts; sweep mouth deeply; attempt to ventilate; repeat until successful
  8. Once ventilation established, check pulse; if absent, begin chest compressions as in CPR, one-person or two-person rescue
  9. Continue CPR until victim revives or help arrives
  10. If victim revives, cover and keep warm reassure victim help is on the way
  11. Rescue personnel can further assist emergency department personnel by:
    1. Documenting prehospital resuscitation methods used
    2. Immobilizing victims suspected of cervical spine injuries
    3. Using a sterile container to take a sample of immersion fluid
    4. Taking on-scene arterial blood gas sample for later analysis
Symptomatic near-drowning victim
  1. Provide basic or advanced
  2. Provide clear airway and adequate ventilation by:
    1. Suctioning airway
    2. Inserting artificial airway and attaching it to ventilator as indicated
    3. Inserting nasogastric tube to suction to minimize aspiration of vomitus
  3. Monitor ECG continuously
  4. Start IV infusion 5% D/W at keep-open rate for fresh water near-drowning; 5% D/NS in salt water near-drowning
  5. Assist with insertion of CVP and Swan-Ganz catheter to guide subsequent infusion rates
  6. Administer drugs as ordered: anticonvulsants; steroids, antibiotics, stimulants, antiarrhythmics
  7. Provide rewarming if hypothermia present
  8. Insert Foley to assess kidney function because fresh water near-drowning causes renal tubular necrosis due to RBC hemolysis
  9. Transfer to ICU when stabilized
 
Sensorium: alert; disoriented, stuporous, comatose
Respirations: increased rate, depth; shallow; asymmetrical; parodoxical breathing; mediastinal shift; gasping, blowing
C/V: signs of shock
Abdomen: contusions; pain; abrasions; open wounds; rigidity; increasing distention
Skeletal system: pain; swelling; deformity; inappropriate or no movement
Neurological: pupils round, equal, react to light; ipsilateral dilation and unresponsive; fixed and dilated bilaterally
Bilateral movement and sensation in all extremities
Progressive contralateral weakness
Loss of voluntary motor function
See Sensorium above for level of consciousness
  1. Do not move patient unless you must, to prevent further injury; send for help
  2. Check breathing - give mouth-to-mouth resuscitation if indicated
  3. Check for bleeding
  4. Control bleeding by applying pressure on wound or on pressure points (artery proximal to wound)
  5. Use tourniquet only if above pressure techniques fail to stop severe bleeding
  6. Check for shock (pulse, pupils, skin color) and other injuries
  7. Fractures; keep open-fracture area clean
  8. Do not try to set bone
  9. If patient must be moved - splint broken bones with splints that extend past the limb joints; tie splints on snugly but not so tight as to cut off circulation
  10. Check peripheral pulses
  11. If head or hack injury suspected - keep body straight; move only with help
  12. Reassure patient that help is on the way
  1. Assess vital functions
  2. Establish airway; ventilate with Ambu-bag, volume cycled ventilator
  3. Draw arterial blood gases
  4. Control bleeding
  5. Support circulation by closed chest massage
  6. Prepare infusions of dextran, blood, crystalloids
  7. Assess for other injuries: head injuries - suspect cervical neck injury with all head injuries
  8. Place sandbags to immobilize head and neck
  9. Do mini-neurological exam:level of consciousness, pupils, bilateral movement. and sensation
  10. Get history - time of injury; any loss of consciousness; any drug ingestion
  11. Stop bleeding on or abouthead
  12. Apply ice to contusions andhematomas
  13. Check for bleeding fromnose, pharynx, ears
  14. Check for cerebrospinal fluid from ears or nose
  15. Assist with spinal tap if ordered
  16. Keep accurate I&O
  17. Protect from injury if restless, seizures; orient to time, place, person
  18. Administer steroids, diuretics, as ordered
  19. Check for signs of increasing intracranial pressure: slowing pulse and respiration, widened pulse pressure, decreasing mentation
Spinal Injuries
    
  1. Assess and support vital functions as above
  2. Immobilize no flexion or extension allowed
  3. If in respiratory distress - nasotracheal intubation or tracheostomy to avoid hyperextending neck
     
  1. Check for level of injury and function, asking patient to:
    1. Lift elbow to shoulder height (C-5)
    2. Bend elbow (C-6)
    3. Straighten elbow (C-7)
    4. Grip your hand (C-8-T-1)
    5. Lift leg (L-3)
    6. Straighten knee (L-4, L-5)
    7. Wiggle toes (L-5)
    8. Push toes down (S-l)
  1. If patient comatose:
    1. Rub sternum with knuckles
    2. If all extremities move, severe injury unlikely
    3. If one side moves and other does not, potential hemiplegia
    4. If arms move and legs do not, lower spinal cord injury
  2. Administer steroids as ordered
  3. Assist with application of skull tongs - Vinke or Crutchfield
  4. Maintain IV infusions
  5. Insert Foley as indicated
  6. Assist with dressing of open
Chest injuries
  
  1. Note color and pattern of respirations, position of trachea
  2. Auscultate lungs and palpate chest for: crepitus, pain, tenderness, and position of trachea
  3. Place gauze soaked in petroleum jelly over open pneumothorax (sucking chest wound) to seal hole and decrease respiratory distress
  4. Assist with tracheostomy if indicated
  5. Prepare for insertion of chest tubes if pneumothorax or hemothorax present
Abdominal injuries
    
  1. Observe for rigidity
  2. Check for hematuria
  3. Auscultate for bowel sounds
  4. Assist with paracentesis to confirm bleeding in abdominal cavity
  5. Prepare for exploratory laparotomy
  6. Insert nasogastric tube - to detect presence of upper GI bleeding
  7. Monitor vital signs
If organs protruding:
  1. Flex patient’s knees
  2. Cover intestines with sterile towel soaked in saline
  3. Do not attempt to replace organs
Fractures
    
  1. Administer tetanus toxoid as ordered
  2. Observe for pain, peripheral pulses, pallor, loss of sensation and/or movement
  3. Assist with wound cleansing, casting, x-rays, reduction
  4. Prepare for surgery if indicated
  5. Monitor vital signs
Bums - tissue trauma secondary to scalding fluid or flame, chemicals, or electricity
Superficial (first degree): Erythema and tenderness Usually sunburn
Relieve pain by applying cold, wet towel or cold water (not iced)
  1. Cleanse thoroughly with mild detergent and water
  2. Apply gauze or sterile towel
  3. Administer sedatives and narcotics as ordered
  4. Arrange for follow-up care, or prepare for admission if burn ambulatory care impractical
 
Partial thickness (second degree):
Swelling, blisters; moisture due to escaping plasma
  1. Douse with cold water until pain relieved
  2. Blot skin dry and cover with clean towel
  3. Do not: break blisters, remove pieces of skin, or apply antiseptic ointments
  4. If arm or leg burned, keep elevated
  5. Seek medical attention if second-degree burns:
    1. Cover 10% of body surface
    2. Involve hands, feet, or face
  1. Check tetanus immunization status
  2. Administer sedatives or narcotics as ordered
  3. Assess respiratory and hemodynamic status; oxygen or ventilatory assist as indicated, intravenous infusions as ordered to combat shock
  4. Remove all clothing from burn area
  5. Using aseptic technique, cleanse burns as indicated.