Chapter 16: Care of Patients Experiencing Urgent Alterations in Health PDF

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Chapter 16 Care of Patients Experiencing Urgent Alterations in Health

Objectives

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List the priorities of assessment to be performed in a situation in which first aid is necessary.  First aid is an immediate initial assistance to preserve life until the medical help arrives. It includes:  Assessing the victim for life-threatening conditions  Performing appropriate interventions to sustain life  Keeping the person in the best possible physical and mental condition until the assistance of (EMS) is obtained Circulatory problems, airway problems, breathing troubles, incessant bleeding, and poisoning are life-threatening situations that call for priority emergency care. The suspect shocks in every situation concerning traumatic injuries, diseases, physical and emotional strain Assessment of life-threatening problem is a priority in an emergency situation. The nurse should:  Assess patient’s circulation, airways, and breathing  Assess rate, rhythm and strength of carotid pulse for not more than 10 seconds  Monitor for signs of external and internal bleeding, which may lead to shock  Assess skin color, temperature, pupil reaction, pulse, and respiration  Circulatory collapse and depressed respiration are possible results of poisoning  Observe for burns or strains in and around the person’s mouth or hands  The victim’s airway is opened  Head-tilt if a neck injury is not suspected  Jaw-thrust (Cervical spine injury) without tilting the head to open the airway. Do not hyperextend the patient’s neck to establish airway; potential for causing or exacerbating a cervical spine injury  Victim’s breathing by whether the chest is rising, and listening to the breathing sounds Once the assessment of life-threatening problem is done, the nurse assesses the victim for indication of skull injury as well as the brain or spinal cord damage. Victim’s fractures, dislocation, and superficial ecchyomoses are treated after treating life-threatening conditions

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Discuss moral, legal, and physical interventions/implications involved in performing first aid.  Moral interventions  Used to enhance the will power of the victim.  Ask the victim about his name and family during the first aid  Make the victim more comfortable, by telling him about his preventable harm  Legal interventions “Good Samaritan Law”  Made to protect the first aid provider in an emergency situation  Follow a reasonable and prudent course of action  Before the administration of first aid, the verbal permission is necessary from the conscious victim  Assumes the consent of an unconscious victim  Legal and moral obligation to continue the aid until the victim can be cared for by someone with comparable or better training (EMT)  Physical interventions  Include the proper information about the injuries of the victim  The emergency medical services (EMS) are to be informed first, after the analysis of the victim  The proper bandage in the case of lacerations and other first aids is assumed to apply to the victim  The victim is, supposed to be checked for his blood pressure, pulse, and proper breathing conditions

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List the reasons for performing cardiopulmonary resuscitation (CPR).  Reasons:  Indicated when the patient is not responsive and not breathing  To keep blood circulation and carrying oxygen to the brain, the heart, and other parts of the body  To keep the airway open and the lungs supplied with oxygen when breathing has stopped  Helps in preventing the cardiac arrest and ultimately improves the survival rate of the victim  Events necessitating CPR:  Cardiac Arrest is usually caused by myocardial infarction (MI)  Respiratory Arrest, trauma to the heart, and shock from hemorrhage, potentially participate in the cardiac arrest.  Electrical shock due to high voltage electricity can cause electrocution. Paralyzes the breathing muscles, which interfere with the normal rhythm of the heart. This interference can lead to cardiac arrest as well.  Anaphylactic reactions, due to the exposure to allergens can cause edema in the upper airway. May lead to cardiovascular collapse  Drug overdose poses the risk of respiratory and cardiac arrest  Asphyxiation or suffocation by inhaling the gases other than oxygen can cause respiratory arrest. May lead to cardiac arrest

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 Sudden infant death syndrome (SIDS) is the unexpected and sudden death of an apparently normal and healthy infant that occurs during seep and with no evidence of disease on physical examination or autopsy. Aspects of prevention include both readiness to perform early CPR and home monitoring systems Events necessitating CPR cont’d  Clinical death  The heartbeat and respirations have ceased  Biologic death  This results from permanent cellular damage caused by lack of oxygen  The brain is the first organ to suffer from lack of oxygen  In many cases, CPR can reverse clinical death if initiated before 4 minutes of cardiopulmonary arrest  After 10 minutes without CPR, brain death is certain  Brain death; irreversible coma  This is an irreversible form of unconsciousness characterized by a complete loss of brain function while the heart continues to beat  The usual clinical criteria for brain death include the absence of reflex activity, movements, and respiration; pupils that are fixed and dilated; and absent electric activity of the brain on two electroencephalograms (EEGs) performed 12 to 24 hour apart Initial assessment and response  Determine responsiveness  Gently shake and loudly ask “Are you OK?” to prevent from injuring a person who is sleeping  Call for help or direct another person to make a telephone call if available  Vitally important to obtain an automatic external defibrillator (AED)  For most successful treatment of cardiac arrest, CPR and use of an AED should be initiated within the first 3 to 5 minutes The CABs of CPR  Circulation  Airway  Breathing HCP and lay persons establish unresponsiveness, activate the EMS, and retrieve the AED  Both determine if there is no breathing or abnormal breathing  Only HCPs assess for the carotid pulse; take no more than 10 seconds to palpate the pulse; the layperson does not assess for a carotid pulse Circulation  Determine pulselessness; indicates the need for cardiac compressions  Carotid pulse is the most reliable & accessible pulse  Maintain the head tilt method for assessing the carotid pulse; one hand on forehead while assessing for the

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presence of a pulse; other hand 2 to 3 fingers locate thyroid cartilage; palpate pulse gently only on one side of the neck; not to obliterate arterial blood flow to the brain  Absence of pulse confirms cardiac arrest  Perform external cardiac compressions  Will circulate blood to the heart, lungs, brain, and the rest of the body  Performing on a victim w/ a pulse has the potential to result in injury to the victim  Proper compression technique  Lock elbows in place with arms straight and shoulders positioned over hands  Lean forward and push, depressing sternum at least 2 inches in adult  Release external chest compression pressure completely to allow chest to return to position; allows blood to flow into the heart  Maintain hand position at all times  Complications of external chest compressions; lacerated liver, fractured ribs, and fractured sternum, bruising or bleeding of the liver, the lungs, and the spleen  Airway  Confirm absence of breathing and establish patent airway  If no evidence of neck trauma, use head-tilt/chin-lift maneuver to open airway  Initiate rescue breathing if pulse present  Preserve open airway  Kneel at shoulders of patient  Use thumb and index finger to maintain the head-tilt position  Gently pinch nostrils  Nurse takes deep breath  Seal lips around outside of victim’s mouth  Give two full breaths 1 second each List the steps in performing one-rescuer and two-rescuer CPR on an adult, child, and infant victim.  Adult One-Rescuer CPR:  Determine unresponsiveness  Determine breathlessness  Call for help  Activate the EMS system 

Circulation  Determine pulselessness; palpate the carotid pulse  Pulse present - initiate rescue breathing about 8 to 10 times per minute, or one breath every 6 to 8 seconds. Activate the EMS system

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 Pulse is not present - perform 30 chest compressions at a rate of at least 100 per minute. Follow compressions with two slow breaths.  Continue with 30 compressions and two slow breaths until an AED becomes available or help arrives Airway  Open airway using head tilt/chin-lift maneuver  If suspected neck injury, use jaw thrust (chin-lift) without head tilt without head tilt Breathing  Not breathing – two slow breaths (1 second each), allowing exhalation between breaths  Unable to give breaths – reposition head and reattempt to ventilate  Still unable – proceed with foreign body airway obstruction management procedures Adult two-rescuer CPR:  If EMS not activated – direct second rescuer to activate EMS  The ventilator – person at victim’s head  Determine responsiveness  Assesses breathlessness for 5-10 seconds  Determine pulselessness  Pulse present – initiate rescue breathing 1 breath every 6-8 seconds (8-10 per minute)  Compressor – person at victim’s chest  Activates EMS and calls for AED  Pulseless – initiate compressions  30 chest compressions for every 2 breaths  Compression rate 100 per minute  More likely to become fatigued  Switch positions every 5 cycles of 2 minutes for effective CPR  Initiated by rescuer performing chest compressions  Checks the pulse for 5-10 seconds  No pulse – “RESUME CPR” Pediatric CPR: Child or Infant  The basic steps of CPR and foreign body airway obstruction management are the same whether the victim is an infant, a child, or an adult  For the purpose of life support  Infant: younger than 1 year  Child: between the ages of 1 year to puberty  Must first determine unresponsiveness  Child – shake gently  Infant – gently tap infant’s heels  Position victim on firm, flat surface  May have to carry small child/infant while performing CPR  Open airway  Use head-tilt/chin-lift or jaw thrust technique

 Be careful not to hyperextend the infant’s neck  Look for chest movement  Listen for breath sounds  Feel exhaled airflow  Not breathing – begin the CAB sequence  Circulation  Technique for external cardiac compressions for infant  Use two fingers to perform chest compressions  Compress breastbone at least 1/3 diameter of chest (1 ½ inches)  Rate 100 times per minute  Ratio of compressions to ventilation is 30:2  Technique for cardiac compression in the child  Compress heel of one hand at nipple line at depth of at least 1/3 diameter of chest (2 inches)  Rate 100 times per minute  Be sure fingers do not touch ribs  Keep compression smooth  Sequence is 30 compressions to 2 breaths; if two HCPs are performing the rescue, the sequence is 15:2 (15 compressions to 2 ventilations)  Airway  Use head-tilt/chin-lift or jaw thrust technique to open airway of child  Breathing  Give 2 breaths (1 second per breath)  Use the amount of air for the infant that an adult is able to hold in the cheeks  Common in infants and children: Gastric detention as a result of over inflation of the lungs 

Identify the steps in performing the abdominal thrusts on conscious and unconscious victims and pregnant victims  An abdominal thrust is an emergency procedure for dislodging a bolus of food or other obstruction from the trachea to prevent asphyxiation. Abdominal thrusts are given below the diaphragm. Thrusts put pressure on the diaphragm, forcing air from the lungs to move and expel the foreign object  Conscious victim:  Performed by any nurse, by wrapping her arms around the waist of the victim. The nurse makes the first to apply pressure above the navel, on the abdomen and well below the xiphoid process. Wrap the other hand over the fist, thrust into the victim’s abdomen with a quick upward motion. The nurse continues the procedure of thrust, until the foreign body is expelled.  Pregnant victim:

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 Chest thrust instead of abdominal thrust is used in the pregnant ladies. The nurse performs the chest thrust by using the position of the hands during the cardiopulmonary resuscitation (CPR). Abdominal thrust will be proved as a harmful procedure, during the pregnancy. This procedure can become the reason of abortion in severe cases.  Unconscious victim:  Performed by any nurse, by laying down the victim in the position of face-up. The removal of the object is allowed only on the condition, if it is visible. Unconscious victim is recommended to provide ventilation and five abdominal thrusts, if ventilation is unsuccessful. The nurse can perform upward thrust by applying the pressure using the heel of the hand on the abdomen, above the navel. Discuss management of airway obstruction in a child and an infant  The nurse can assist a child in the similar manner, that for an adult to manage the airway obstruction using the abdominal thrust.  Child:  Performed by any nurse, by wrapping her arms around the waist of the victim. The nurse makes the first to apply pressure above the navel, on the abdomen of the victim. The nurse continues the procedure of thrust, until the foreign body is expelled  Infant:  This includes, the chest thrusts and back blows.  First step includes the support and held down of the face of an infant. Five back blows using the force by the heel of the hand given very quickly.  Second step includes the back-laying position, followed by placing the two fingers on the breastbone. Five downward thrusts given so, quickly in this position Discuss the signs and symptoms of shock and interventions to treat shock.  Shock is an abnormal conditions of inadequate blood flow to the body’s peripheral tissues, with life-threatening cellular dysfunction, hypotension, and oliguria  It results from failure of the cardiovascular system to provide sufficient blood circulation to the body’s tissues and decreased metabolic waste removal  To maintain circulatory homeostasis, there must be a functioning heart to circulate blood and a sufficient volume of blood  Most common causes of the shock are the severe blood loss, burns, extensive trauma, poisons, emotional stress, electrical injuries, and severe illness.  Shock type & Required therapy  Cardiogenic: Dilation of aortic arteries, use of vasodilators to increase cardiac output, thrombolytic therapy, revascularization  Hypovolemic: blood and fluid replacement, surgery, bleeding control  Septic: Fluid replacement, use of ionotropic agents, vasopressors, antibiotics  Anaphylactic: Bronchodilators that can be inhaled, corticosteroids, epinephrine, colloidal fluid replacement

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Assessment: S/S:  A change in the level of consciousness  Skin temperature and color changes; Due to vasoconstriction of blood vessels in skin and abdominal viscera  Decreased blood pressure; Due to vasodilation of vessels of heart, skeletal muscles and respiratory system  Increased pulse rate and respirations  Diminished urinary output  Muscle weakness or tremors  Pupil dilation  Nausea and vomiting  Nursing Interventions:  Primary Interventions:  Establishment of airway  Fluid replacement  Control bleeding  Position the victim flat with the head slightly lower than the rest of the body & elevate the feet and legs slightly higher than head (6-8 in); helps to improve the venous flow to the right side of the heart and to the vital organs & helps increase cardiac output; Trendelenburg’s position is not recommended  If the victim is unconscious or is vomiting or bleeding around the nose or mouth, position on the side  If victim is having breathing problems, elevate head and shoulders  Avoid hyperextension of the neck to protect against potential neck or spine injuries  Reduce pain  Cover victim with a blanket or other covering to keep warm  Do not allow anyone to administer food or fluids; in case of internal injuries are present  Relieve pain: support injury; avoid rough handling; adjust tight or uncomfortable clothes  Provide a moistened cloth to help relieve dryness of the mouth or mucous membranes  Do not give analgesics unless directed by a HCP  Provide emotional support and reassurance Discuss three methods of controlling bleeding.  Bleeding and Hemorrhage  Average adult has approximately 5 to 6 L (8 to 12 pints) of blood circulating in the bloodstream  Effects of blood loss:  Blood loss from internal or external bleeding causes a decrease in oxygen supply to the body  Blood pressure drops

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 Heart pumps faster to compensate for the decreased volume and blood pressure  The body will attempt to clot the blood to halt bleeding, usually requiring 6-7 minutes  Major blood loss or uncontrolled bleeding may lead to shock, death, or severe hemorrhage Types of Bleeding  Capillary  Most common type of external hemorrhage; results from damaged or broken capillaries and causes oozing of minor cuts, scratches, and abrasions  Venous  Occurs when the vein is severed or punctured  Results in a slow, even flow of dark red blood  Air embolism may occur if air enters the severed vein; an abnormal circulatory condition in which air travels through the bloodstream and becomes lodged in a blood vessel  Arterial  Least common; deep in the body and usually protected by bones, fat, and other structures  Heavy spurting of bright red blood in the rhythm of the heartbeat  Most common sites: Femoral (in the upper thigh and groin) Radial (in the medial aspect of the lower arm) Brachial (in the medial aspect of the upper arm) Carotid (on either side of the neck) Nursing Interventions:  Direct pressure  The most effective general treatment of bleeding is to apply direct pressure over the bleeding site  Bleeding is usually controlled in 10 to 30 minutes; do not allow anyone but a HCP to remove the bandage while exerting direct pressure, even if it becomes saturated with blood  Raising the bleeding part of the body above the level of the heart will decrease the amount of blood flow and increase the body’s ability to clot at the site

 Indirect pressure  If direct pressure and elevation do not control bleeding, indirect pressure may be applied to any of the pressure points situated along main arteries; brachial, carotid, subclavian, and femoral

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Pressure can be applied using the fingers or the heel of the hand to compress the artery against the underlying bone located between the heart and the wound; should do this only if no fractures are suspected in the area where pressure could be applied  Application of a tourniquet  Usually strapped around the leg or arm to tighten the area  A tourniquet must be used only when the other methods have failed and the victim’s life is in danger  It can cause extensive damage to the body part  Discuss the five general types of open wounds: abrasions, incisions, lacerations, punctures, and avulsions. The internal or external body tissues, when gets injured is termed as a wound. The wound can be closed or open. The closed wounds do not break the top layer of the skin rather it involves the underlying tissues of the body. Open wounds involve the injury to the top layer of the skin. The bleeding is the most common event during the open wound. 

Open wounds always have a chance of infection and uncontrolled bleeding in certain cases  Abrasions  Scraping or rubbing can harm the outer layer of the skin  Bleeding is limited, but there is a chance of infection by microorganism and dirt  Ex: rope and road burns, scratches, and scrapes of knees and elbows Nursing Interventions  All dirt should be removed, if possible  Strong antiseptics should not be used; can easily irritate the skin  Normal saline is safe and effective; copious irrigation w/ saline helps remove debris  Incisions  Smoothly divided wounds made by sharp instruments  Blood f...