Clinical emergencies- Medical Surgical Nursing

Mrs.Puvaneswari. K

Assoc.Professor

NHCON

MEDICAL AND SURGICAL CONDITIONS CONSIDERED AS EMERGENCY

Acute abdomen

Shock

Respiratory emergencies

Cardiac emergencies

Neurologic emergencies

Trauma

Poisoning

Acute abdomen

Abdominal pain is a symptom of many

different types of tissue injury and can arise

from damage to abdominal or pelvic organs

and blood vessels.

Abdominal emergency- Conditions

Minutes -

Perforated ulcer or diverticulum,

ruptured AAA, testicular or ovarian torsion, ectopic

pregnancy, pancreatitis, mesenteric infarct

Hours-

Biliary disease, appendicitis, diverticulitis, SBO

Days -

Inflammatory bowel disease, malignant obstruction

Assessment of acute abdomen

History

Assess for Pain

Nausea, vomitting,

Diarrhoea, Constipation,

Flatulence

Fatigue, Fever,

Increase abdominal

girth.

Board like abdomen

Diagnostic tests.

Abdominal X-ray

CBC

Urine analysis.

Ultra sound

CT scan

NURSING - Physical assessmentV

ital Signs

• Tachycardia - volume loss ( Shock)

• Rapid shallow breathing- PeritonitisBowel sounds

• Auscultate before palpating• Absent sounds- possible peritonitis,

shock• High pitched tinkling sounds - Possible

bowel obstruction

Position and general appearance

• Still refusing to move - inflammation or Peritonitis

• Extremely restless - obstruction

Medical and Nursing Management

Oxygen administration

IV of Lactated Ringers or Normal Saline Solution

Keep patient warm

Monitor vital signs

Monitor EKG

Insert Ryles tube for aspiration if needed

Treat pain as per protocols (some believe that

masking/treating pain is wrong)

Administer anti emetics

Perioperative care

Prepare the patient for emergency surgery.

Keep the client on NPO.

Post operatively keep low suction NG tube

Maintain intake output chart.

Routine mouth care and nasal care is essential.

Check for abdominal distension- (Early ambulation )

Drainage care.

Follow aseptic procedures.

SHOCK

Shock is a condition characterised by

decreased tissue perfusion and impaired

cellular metabolism

SurgicalMedical

Causes of Shock

Post op bleeding

GI bleeding

Aortic dissection

Ruptured Ectopic

pregnancy

Ruptured organ or

vessel

MI

Dehydration

Sepsis

Diabetes Insipidus

Addisonian crisis

Trauma

Fracture

Assessment And Diagnostic tests

Nurses can Assess for

Restlessness, Rapid and thready pulse,

Hypotension, Cool and Clammy skin, cyanosis,

Decreased LOC, Nausea and vomitting.

Perform Emergency

ECG

Cardiac monitoring,

Pulse oxymetry.

ABG, Haemodynamic monitoring and CT scan

Medical and nursing management

Initiate patent airway

Administer high flow oxygen

Anticipate need for intubation and mechanical

ventillation

Establish IV access and administer NS and crystalloids

Assess for life threatening injuries

Consider vasopressor therapy only after the

hypovolemia is corrected

Treat dysarrythmias.

Cardiac emergencies

Myocardial infarction

Cardiac tamponade

Cardiogenic shock

Pulmonary embolism

Sudden cardiac death

GENERAL ASSESSMENT

Observe overall appearance of the patient, age, body position

Assess for LOC, pain , edema, Nausea, vomiting, fatigue, headache , palpitations , Pale skin and cyanosis

AIRWAY AND BREATHING

Evaluate the patient’s ventilatory status for rate , depth of breathing, respiratory effort, and tidal volume.

Assess lung sounds - crackles or rales.

CIRCULATION

Evaluate distal pulse rate, quality (strength), and rhythm, temperature,

Look for any external bleeding

NURSING ASSESSMENT AND INVESTIGATIONS

History - Previous associated problems ( HT,DM)

Detailed Physical examination

ECG and Echocardiography

X-ray and Cardiac enzymes

Arterial Blood Gases (ABG)

Ventilation Perfusion Lung Scan (VQ scan)

CT , Pulmonary Angiography

Medical And Nursing managementMaintain an open airway, remove secretions,

vomitus

Initiate CPR with supplemental high concentration

of oxygen.

Place the patient in a position of comfort

Open IV access , Connect to ECG, Pulse oxymetry

Defibrillation if needed.

Mechanical Ventilator- Assisted ventilation or

CPAP is often helpful

Medical And Nursing managementMonitor vital signs.

Fluid restriction if needed

Maintenance of intake and output chart.

Foot end elevation in Hypotension.

Do not give NTG if the BP is low. Administer

NTG if BP is high

Administer Emergency Cardiac drugs –

Inotropes, Diuretics, Cardiac glycosides,

Narcotics, Atropine, Adrenaline etc

Respiratory emergencies

Pneumothorax

Airway obstruction

Status asthmaticus

Acute pulmonary edema

Respiratory distress

Nursing assessment

•Onset•Provocation•Quality•Radiation•Severity•Time

•Initial Exam

•Body position , Skin signs and color, Respiratory

rate and effort, Mental status , Pulse (rate &

character) Focused Exam (S)

Signs and symptomsAllergies (med allergies)MedicationsPast medical historyLast meal or intakeEvents leading to call

Diagnostic tests

Physical examination

Pulse oxymetry

ABG

X-ray

PFT

CT/MRI

Tension Pneumothorax

Needle decompression

Place Flutter valve

Prepare for chest tube insertion.

Surgical management – Thoracotomy

Open Pnuemo- thorax

Observe for the development of tension

pneumothorax

Cover the wound with an 3 sided occlusive

dressing

Asherman

Chest seal

Airway obstruction

Simultaneous protection of the C-spine .

ETT or Nasotracheal tube intubation

Tracheostomy and Cricothyrotomy

Epinephrine administration

Cardiopulmonary resuscitation (CPR)

Status Asthmatics

• Correct Hypovolemia and mechanical

ventillation

• Administer Short acting Inhaled B2 agonists

• Nebulisation with anti cholinergics

• IV corticosteroids

• Oxygen therapy

Neurologic emergencies

Stroke

Altered Consciousness and Coma

Status epilepticus

Haemorrhage

Spinal shock

Nursing Assessment and Diagnostic AidsHistory and Physical examination

Four domains to examine:

Pupillary responses

Extraoccular movements

Respiratory pattern

Motor responses

Glasgow coma scale (GCS)

Emergency CT scan with Contrast, EEG

Medical and nursing management

ABCs - insure adequate oxygenation and blood

pressure before proceeding

Blood glucose to be maintained normal.

Airway control and prevention of hypercapnea

are crucial - ventillator

When intubating patients with elevated ICP use

thiopental, etomidate, or intravenous lidocaine.

Medical and nursing management ICP monitoring

Avoid jugular vein compression , Head should be in neutral position , Cervical collars should not be too tight

Pharmacologic options

Mannitol 0.25 gm/kg q4h

Hypertonic saline, , Steroids.

Lorazepam (Ativan) IV 0.1 mg/kg

Propofol , Phenobarbital IV 20 mg/kg ,

Valproate IV 20 - 30 mg/kg

Medical and nursing management

Immediate IV access to be established

Check metabolic panel, drug screen

Follow aseptic techniques.

CVP, ETT, Surgical Drains

Fluid and electrolyte management.

Trauma

Head injury.

Chest lnjury

Abdominal injury

Vascular injury

Primary Survey Secondary SurveyAssessment

ABCDEs of trauma care

A - Airway

B - Breathing

C - Circulation

D - Disability

E – Exposure

AMPLE history

Physical exam

Reassessment of

vitals

Diagnostic studies

Nursing- Assessment

Breathing

Unlaboured No breathingLaboured

BewareChest injury

PneumothoraxContusionFlial chest

Head injurySpinal injury

Investigations

Standard trauma labs

ABG , CBC, Electrolytes

PTT, Blood Glucose

CT/ MRI

Chest radiographs

ECG and ECHO

FAST scans

TEE

Aortography

Medical and nursing managementAssess ABC, Vitals.

Provide cervical collar.

CPR

Clear the airway, Administer High flow oxygen

Assess for internal bleeding. Control External

bleeding

Keep the client in NPO.

Position the client . Avoid unnecssary movement.

Open IV access .Administer Fluids

Poisoning

Any substance that can cause injury, illness or

death when introduced into the body.

Inhaled poison

Ingested poison

Absorbed poison

• Injection

The signals of poisoning include

• Trouble breathing.

• Nausea or vomiting.

Chest or abdominal

pain

Changes in

consciousness.

Seizures.

Headache.

Dizziness.

Irregular pupil size.

Burning or tearing

eyes.

Sweating.

Abnormal skin color.

Assessment

Assessment, including evaluation of airway,

breathing, and circulation (the ABCs).

History and Physical examination

Obtain laboratory tests- Toxin level

ECG

Imaging studies ( X-ray)

Nursing care of the poisoned patient

Stabilize the ABCs.

Use the coma cocktail —DONT (dextrose,

oxygen, naloxone, and thiamine)

Perform gastric decontamination, if indicated.

Consider enhanced elimination techniques.

Use an antidote, if indicated, and/or deliver

specific care or symptomatic/supportive care.

Nursing management – NANDA DiagnosisAcute pain

Decreased cardiac output

Inability to sustain spontaneous ventilation

Ineffective breathing pattern

Impaired gas exchange

Impaired tissue perfusion

Deficient Fluid volume