CARE OF CLIENT IN ACUTE BIOLOGIC CRISIS

OBJECTIVES
Given relevant questions, the students will be able to discuss triage and principles in emergency nursing care. 1. identify clinical situations where the client is in acute biologic crisis 2. distinguish acute biologic crisis situations in terms of: a. etiologic factors b. pathophysiology c. clinical manifestations and laboratory exams d. complications e. emergency treatment/management 3. Given a list of emergency drugs, the students will be able to: a. match these drugs with their corresponding actions and therapeutic uses b. list common side effects and adverse reactions c. enumerate dosage and dosage administration

OBJECTIVES
4. determine/identify health care problems based on: a. health history b. physical examination c. laboratory examinations 5.Formulate relevant nursing diagnosis 6. Discuss/demonstrate appropriate nursing interventions 7. Evaluate outcome of health care 8. Verbalize appreciation on the influence of Christian values in health care

DEFINITION
Emergency Management refers to care given to patients with urgent and critical needs. However, because many people lack access to health care, the emergency department is increasingly used for non-urgent problems. Therefore, the philosophy of emergency management has broadened to include the concept that an emergency is whatever the patient or the family considers it to be.

Scope and Practice of Emergency Nursing

1. The emergency nurse has had specialized education, training, experience, and expertise in assessing and identifying patients health care problems in crisis situations.

2. The emergency nurse establishes priorities, monitors and continuously assesses acutely ill and injured patients, supports and attends to families, supervises allied health personnel, and teaches patients and families within a time-limited, high-pressured care environment

3. Nursing interventions are accomplished interdependently, in

consultation with or under the direction of a physician or nurse practitioner. The strengths of medicine and nursing are complementary in an emergency situation. Appropriate nursing and medical interventions are anticipated based on assessment data. The emergency health care staff members work as a team in performing the highly technical hands-on skills required to care for patients in emergency situations. 4. Patients in the ER have a wide variety of actual or potential problems, and their condition may change constantly. Therefore, nursing assessment must be continuous, and nursing diagnoses change with the patients condition. Although a patient may have several diagnoses at a given time, the focus is on the most life-threatening ones; often both independent and interdependent nursing interventions are required.

Issues in Emergency Nursing Care

1. Documentation of Consent and Privacy 2. Limiting Exposure to Health Risks 3. Violence in the Emergency Department a. Safety is the first priority. Protection of the department provides protection for the patients, families, and staff. b. Metal detectors, silent alarm systems, and secured entry into the department assists in maintaining safety. c. Members of gangs and feuding families need to be separated in the ER, waiting room and later in the ward to avoid angry confrontations d. Security personnel should be ready to assist at all times. The ER should be able to be locked against entry if security is at all in question.

Issues in Emergency Nursing Care

e. Patients from prison and those who are under guard need to be handcuffed to the bed and appropriately assessed to ensure the safety of the hospital staff and other patients.

e.1. never release the hand or ankle restraint (handcuff) e.2. always have a guard present in the room. e.3 place the patient face down on the stretcher to avoid injury from head-butting, spitting, or biting. e.4 use restraints on any violent patient as needed. e.5. administer medication if necessary to control violent behavior until definitive treatment can be obtained. f. In the case of gunfire in the ER, self-protection is a priority. There is no advantage to protecting others if the caregivers are also injured. Security officers and police must gain control of the situation first, and then care is provided to the others.

Issues in Emergency Nursing Care

4. Providing Holistic Care
a. patient-focused interventions

the unconscious patient should be treated as if conscious; that is, the patient should be touched, called by name, and given an explanation of every procedure that is performed. b. Family-focused interventions The family is kept informed about where the patient is, how he/she is doing, and the care that is being given. Allowing the family to stay with the patient, when possible also helps allay their anxieties

Guidelines in Helping Family Members Cope with Sudden Death

1. Take the family to a private place. 2. Talk to the family together, so that they can mourn together. 3. Reassure the family that everything possible was done; inform them of the treatment rendered. 4. Avoid using euphemisms such as passed on. Show the family that you care by touching, offering coffee, water, and the services of the chaplain. 5. Encourage family members to support each other and to express emotions freely (grief, loss, anger, helplessness, tears, disbelief).

6. Avoid giving sedation to family members; this may

mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression. 7. Encourage the family to view the body if they wish; this action helps to integrate the loss. Cover disfigured and injured areas before the family sees the body. Go with the family to see the body. Show acceptance by touching the body to give the family permission to touch. 8. Spend time with the family members to talk about the deceased and what he/she meant to them; this permits ventilation of feelings of loss. Encourage the family to talk about events preceding admission to the ER. Do not challenge initial feelings of anger and denial. 9. Avoid volunteering unnecessary information (e.g., the patient was drinking)

Principles of Emergency Care

By definition, emergency care is care that must be rendered without delay. In an ER, several patients with diverse health problemssome life threatening, some not may present to the ED simultaneously. One of the first principles of emergency care is triage. TRIAGE comes from the French word trier, meaning to sort. In the daily routine of the ER, triage is used to sort patients into groups based on the severity of their health problems and the immediacy with which these problems must be treated.

Systems
Categories 1. Emergent patients have the highest priority their conditions are life-threatening and they must be seen immediately. 2. Urgent patients have serious health problems but not immediately life-threatening ones; they must be seen within 1 hour. 3. Nonurgent patients have episodic illnesses that can be addressed within 24 hours without increased morbidity. 4. Fast Track patients require simple first aid or basic primary care and may be treated in the ER or safely referred to a clinic or physicians office

Triage Systems
Levels 1. Resuscitation patients need treatment immediately to prevent death. 2. Emergent - patients may deteriorate rapidly and develop a major life threatening situation or require time-sensitive treatment. 3. Urgent Patients have non-life threatening conditions but require two or more resources to provide their care. If the patients vital signs deviate significantly from their baseline, they may require up-triaging to the emergent category. 4. Nonurgent- patients have non-life threatening conditions and likely need only one resource to provide for their needs. 5. Minor category patients have no life-threatening conditions and likely require no resources to provide their evaluation and management. Resources are defined as imaging studies, medications administered IV or IM routes, and invasive procedures. Insertion of an indwelling catheter is an example of a one-resource procedure. Moderate sedation would be classified as a tworesource procedure because this requires frequent monitoring and IV medications.

QUESTIONS - ER
The following questions reflect the minimum information that should be obtained from the patient or from the person who accompanied the patient to the ER: 1. What were the circumstances, precipitating events, location and time of the injury or illness? 2. When did the symptoms appear? 3. Was the patient unconscious after the injury or onset of illness? 4. How did the patient get to the ER? 5. What was the health status of the patient before the injury or illness? 6. Is there a history of medical illness or previous surgeries? A history of admissions to the hospital?

7. Is the patient currently taking any medications, especially hormones, insulin, digitalis or anticoagulants? 8. Does the patient have any allergies, especially to eggs, latex, medications, or nuts? 9. Does the patient have any fears? Does the patient feel that he or she is in a situation in which he/she is unsafe? 10. When was the last meal eaten? 11. When was the LMP? 12. Is the patient under a physicians care? What are the name and location of the physician? 13. What was the date of the patents most recent tetanus immunization?

Assess and Intervene

A systematic approach to effectively establish and treat health priorities is the primary / secondary approach. The primary survey focuses on stabilizing lifethreatening conditions. The ER staff work collaboratively and follow the ABCD (airway, breathing, circulation, disability method: 1. Establish a patent airway. 2. Provide adequate ventilation, employing resuscitation measures when necessary. (trauma patients must have the cervical spine protected and chest injuries assessed first). 3. Evaluate and restore cardiac output by controlling hemorrhage, preventing and treating shock, and maintaining or restoring effective circulation. This includes the prevention and management of hypothermia. 4. Determine neurologic disability by assessing neurologic function using the Glasgow Coma Scale.

Secondary Survey
After these priorities have been addressed, the ER team proceeds with the secondary survey. This includes the following: 1. A complete health history and head-to-toe assessment 2. Diagnostic and laboratory testing 3. Insertion or application of monitoring devices such as ECG electrodes, arterial lines, or urinary catheters. 4. Splinting of suspected fractures 5. Cleansing, closure, and dressing of wounds 6. Performance of other necessary interventions based on the patients condition.

SHOCK
Is a syndrome in which the circulation or perfusion of blood is inadequate to meet tissue metabolic demands. Cellular anoxia will ensue and lead to tissue death unless the process is reversed. During shock, the body struggles to survive, calling on all its homeostatic mechanism to restore blood flow

Classifications of Shock
1. Hypovolemic shock refers to a state in which the volume contained within the intravascular compartment is inadequate for perfusion of body tissue. There is usually a 15%-25% reduction of intravascular volume. e.g., hemorrhagic shock loss of whole blood about 1/3 of his normal blood volume 2. Cardiogenic shock which occurs when the heart has an impaired pumping ability; it may be of coronary or noncoronary event origin. 3. Septic shock- which is caused by an infection 4. Neurogenic shock- which is caused by alterations in vascular smooth muscle tone, caused by either nervous system injury or complications associated with medications such as epidural anesthesia. 5. Anaphylactic shock which is caused by hypersensitivity reaction.

Stages of Shock
1. Compensatory stage

the BP remains normal. Vasoconstriction , increased HR, and increased contractility of the heart stimulation of the SNS and subsequent release of cathecolamines. The body shunts blood from organs to the brain and heart

Compensatory Mechanism in Shock

Initial physiologic insult to shock state Decrease in CO and tissue perfusion SNS activation Endocrine response

RAA activation Vasoconstriction and activation of ADH - Preload

BP, HR, and Myocardial contractility Renal system conserves Na and H2O - Preload

vascular compliance, blood volume and CO Restoration of tissue perfusion (Renin-angiotensin aldosterone)

Medical Management
1. identifying the cause of the shock, correcting the underlying disorder so that shock does not progress, and supporting those physiologic processes that thus far have responded successfully to threat. 2. Fluid replacement and medication therapy must be initiated to maintain an adequate BP and reestablish and maintain adequate tissue perfusion.

Nursing Management
1. Monitoring Tissue Perfusion
a. assess the patient at risk for shock systematically to recognize the subtle clinical manifestations of the compensatory stage before the patients BP drops b. Observe for changes in LOC, VS, urinary output, skin and laboratory values c. Administer prescribed fluids and medications.

2. Reducing anxiety
a. provide brief explanations about the diagnostic and treatment procedures b. Speaking in a calm, reassuring voice and using gentle touch also help ease the patients concerns.

3. . Promoting safety

2. Progressive Stage
the mechanisms that regulate BP can no longer compensate Patients are clinically hypotensive; this is defined as a SBP of <90mmHg or a decrease in SBP of 40mmHg.

Assessment and Diagnostic Findings 1. Respiratory Effects

decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Respirations are rapid and shallow; crackles are heard over the lung fields. Decreased pulmonary blood flow causes arteriolar O2 levels to decrease and CO2 levels to increase. The hypoperfused alveoli stop producing surfactant and subsequently collapse. Pulmonary capillaries begin to leak, spilling their contents, thus causing pulmonary edema, diffusion abnormalities (shunting), and additional alveolar collapse.

Assessment and Diagnostic Findings

2. Cardiovascular Effect

ischemia and dysrhythmia due to lack of adequate blood supply, the HR is rapid, sometimes exceeding 150 bpm. The patient may complain of chest pain and even suffer a myocardial infarction. Levels of cardiac enzymes increase. myocardial depression and ventricular dilation may further impair the hearts ability to pump enough blood to the tissues to meet oxygen requirements.

3. Neurologic Effects- mental status deteriorates and occur with

decreased tissue perfusion and hypoxia. Initially, patient may exhibit a subtle change in behavior or agitation and confusion. Subsequently, lethargy increases, and the patient begins to lose consciousness.

Assessment and Diagnostic Findings

3. Hepatic effects decreased blood flow to the liver impairs the ability of the liver cells to perform metabolic and phagocytic functions. The patient is less able to metabolize medications and metabolic waste products, such as ammonia and lactic acid. Metabolic activities of the liver (gluconeogenesis and glycogenolysis) are impaired. The patients become more susceptible to infection as the liver fails to filter bacteria from the blood. Liver enzymes and bilirubin levels are elevated and the patient appears jaundiced. 4. Renal Effects GFR decreases. ARF may develop (increased BUN, crea), fluid and electrolytes shift, acidbase imbalances and a loss of renal-hormonal regulation of BP.

Assessment and Diagnostic Findings

5. GI effects can cause stress ulcers in the stomach, putting the patient at risk for GI bleeding. In the small intestine, the mucosa can become necrotic and slough off, causing bloody diarrhea. 6. Hematologic Effects the combination of hypotension, sluggish blood flow, metabolic acidosis, coagulation system imbalance, and generalized hypoxemia can interfere with normal hemostatic mechanism.

Medical Management
Will depend on the specific type of shock and its underlying cause. It also depends on the degree of decompensation in the organ system 1. optimizing intravascular volume 2. supporting the pumping action of the heart 3. improving the competence of the vascular system 4. supporting the respiratory system 5.Early enteral nutritional support, aggressive hyperglycemic control with IV insulin and use of antacids, H2 receptor blockers or antipeptic agents to reduce the risk of GI ulceration and bleeding.

Nursing Management
1. Preventing complications
a. monitor the patient for early signs of complications. It includes evaluating blood levels of medications, observing invasive vascular lines for signs of infection, and checking neurovascular status if arterial lines are inserted. b. frequent oral care, aseptic suction technique, turning, and elevating the head of the bed to prevent aspiration. c. positioning and repositioning of the patient to promote comfort and maintain skin integrity.

2. Promoting Rest and comfort to minimize the cardiac workload. 3. Supporting family members

3. Irreversible (refractory) Stage represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive Medical Management: Is usually the same as for the progressive stage. Strategies that may be experimental may be tried to reduce or reverse the severity of shock.

Nursing Management
1. 2. 3. 4. 5. carry out prescribed treatments, monitoring the patient, preventing complications, protecting the patient from injury, and providing comfort. Offer brief explanations to the patient about what is happening is essential even if there is no certainty that the patient hears or understands what is being said. Simple comfort measures, including reassuring touches, should continue to be provided despite the patients nonresponsiveness to verbal stimuli. As it becomes obvious that the patient is unlikely to survive, the family must be informed about the prognosis and likely outcome. Opportunities should be provided, throughout the patients care, for the family to see, touch, and talk to the patient. Close family friends or spiritual advisors may be of comfort to the family members in dealing with the inevitable death of their loved one.

6.

Overall Management Strategies in Shock 1. Fluid replacement intravascular tone

Crystalloid
NSS LRs

to

restore

Colloid Solutions
Dextran

Overall Management Strategies in Shock

Complications of Fluid Administration The most common and serious side effects of fluid replacement are cardiovascular overload and pulmonary edema. Management:
1. Monitor frequently the urine output, changes in mental status, skin perfusion, and changes in vital signs. 2. Lung sounds are auscultated frequently to detect signs fluid accumulation. Adventitious lung sounds, such as crackles may indicate pulmonary edema. 3. A CVP may be inserted to monitor the patients response to fluid replacement. 4. Vasoactive medications to restore vasomotor tone and improve cardiac function. 5. Nutritional support to address the metabolic requirements that are often dramatically increased in shock. Patient in shock may require 3000 calories daily. The release of catecholamines early in shock continuum causes depletion of glycogen stores in about 8-10 hours.

HYPOVOLEMIC SHOCK
Is the most common type of shock and is characterized by a decreased intravascular volume. Body fluids is contained in intracellular and extracellular compartments. Intracellular fluids account for about 2/3 of the total body water. Hypovolemic shock occurs when there is a reduction in intracellular volume by 15%-25%, which represents a loss of 750 1300 ml of blood in a 70-kg person.

Risk Factors for Hypovolemic Shock

A. External: Fluid Losses B. Internal: Fluid Shifts

1. Trauma 2. Surgery 3. Vomiting 4. Diarrhea 5. Diuresis 6. Diabetes Insipidus

1. Hemorrhage 2. Burns 3. Ascites 4. Peritonitis 5. Dehydration

Medical Management
Goals:

1. restore intravascular volume to reverse the sequence of events leading to inadequate tissue perfusion 2. redistribute fluid volume 3. correct the underlying cause of the fluid loss as quickly as possible.

Hypovolemic Shock
Interventions: 1. Treatment of the underlying cause a. If hemorrhaging, applying pressure to the bleeding site or surgery to stop bleeding. b. If due to diarrhea or vomiting, medications to treat diarrhea and vomiting are administered while efforts are made to identify and treat the cause 2. Fluid and Blood replacement 3. Redistribution of fluid 4. Pharmacologic therapy

Nursing Management
1. Administering blood and Fluid safely 2. Implementing other measures
a. oxygen is administered to increase the amount of oxygen carried by available hemoglobin in the blood. b. The nurse must direct efforts to the safety and comfort of the patient.

CARDIOGENIC SHOCK
Occurs when the hearts ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues Types: 1. Coronary cardiogenic shock occurs when a significant amount of the left ventricular myocardium has been damaged. 2. Noncoronary cardiogenic shock are related to conditions that stress the myocardium (e.g., severe hypoxemia, acidosis, hypoglycemia, hypocalcemia, and tension pneumothorax) as well as conditions that result in ineffective myocardial function (e.g., cardiomyopathies, valvular damage, cardiac tamponade, dysrhythmias)

Pathophysiology
Decreased cardiac contractility

Decreased stroke volume and cardiac output

Pulmonary congestion Decreased systemic tissue perfusion decreased coronary artery perfusion

Clinical Manifestations: Patients in cardiogenic shock may experience the pain of angina and develop dysrhythmias and hemodynamic instability.

Medical Management
1. Correction of underlying cause
a. In the case of coronary cardiogenic shock, the patient may require thrombolytic therapy, angioplasty, CABG, intra-aortic balloon pump therapy, or some combination of these treatments. b. In the case of noncoronary cardiogenic shock, interventions focus on correcting the underlying cause, such as replacement of a faulty cardiac valve, correction of dysrhythmias, correction of acidosis and electrolyte disturbances, or treatment of the tension pneumothorax.

2. Initiation of First-Line treatment

a. b. c. d. e. supplying supplemental oxygen controlling chest pain providing selected fluid support administering vasoactive medications controlling HR with medication or by implementation of a transthoracic IV pacemaker.

3. Oxygenation via nasal cannula at 2-6 lpm 4. Pain control IV morphine sulfate. 6. Laboratory marker monitoring (cardiac enzymes)

Nursing Management
1. Preventing cardiogenic shock
a. conserve patients energy b. restore adequate cardiac function and tissue perfusion

2. Monitoring hemodynamic status:

a. arterial lines b. ECG c. Cardiac, pulmonary and laboratory values

3. Administering medications and IV Fluids 4. Maintaining Intra-aortic balloon counterpulsation 5. Enhancing safety and comfort

CIRCULATORY SHOCK
Occurs when blood volume is abnormally displaced in the vasculature (e.g., when blood pools in peripheral blood vessels). Circulatory shock can be caused either by a loss of sympathetic tone or by release of biochemical mediators from cells. Classifications: 1. Septic shock 2. Neurogenic shock 3. Anaphylactic shock

Pathophysiology
Precipitating event Vasodilation Activation of inflammatory response

Misdistribution of blood volume

Decreased venous return Decreased cardiac output Decreased tissue perfusion

Risk Factors for Circulatory Shock

1. Septic Shock a. Immunosuppression b. Extremes of age (< 1 yr and > 65 yr) c. Malnourishment d. Chronic illness e. Invasive procedures 2. Neurogenic Shock a. Spinal cord injury b. Spinal anesthesia c. Depressant action of medications d. Glucose deficiency 3. Anaphylactic Shock a. Penicillin sensitivity b. Transfusion reaction c. Bee sting allergy d. Latex sensitivity e. Severe allergy to some foods or medications

Septic Shock
Septic Shock: shock associated with sepsis; characterized by symptoms of sepsis plus hypotension and hypoperfusion despite adequate fluid volume replacement Medical Management: 1. Identification of the cause of infection. Specimens of blood, sputum, urine, wound drainage, and tips of invasive catheters are collected for culture using aseptic technique. 2. Any potential source must be eliminated. IV lines are removed and reinserted at other body sites. Antibiotic-coated IV central lines may be inserted to decrease the risk of invasive line-related bacteremia in high risk patients, such as elderly. 3. Fluid replacement must be instituted to correct the hypovolemia that results from incompetent vasculature and the inflammatory response. 4. Pharmacologic therapy. 5. Nutritional therapy

Nursing Management
1. All invasive procedures must be carried out with aseptic technique. 2. Monitor patient for signs of infection. 3. Administer prescribed IV fluids and medications, including antibiotic agents and vasoactive medications to restore vascular volume. 4. Laboratory values must be monitored. 5. Monitor hemodynamic status

Neurogenic Shock
vasodilation occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation. The patient experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period leading to a relative hypovolemic state. However, blood volume is adequate, because the vasculature is dilated; the blood volume is displaced, producing hypotensive state resulting to a drastic decrease in the patients systemic vascular resistance and bradycardia. Inadequate BP results in the insufficient perfusion of tissues and cells. Causes: 1. Spinal cord injury, spinal anesthesia, or nervous system damage. 2. Depressant effect of medications or from lack of glucose.

Medical Management
1. restoring sympathetic tone, either through stabilization of a spinal cord injury or, in the instance of spinal anesthesia, by positioning the patient properly. 2. If hypoglycemia is the cause, glucose is rapidly administered

Nursing Management
1. Elevate and maintain the head of the bed elevated at least 30 degrees to prevent neurogenic shock when a patient receives spinal or epidural anesthesia. Elevation of the head helps prevent the spread of the anesthetic agent up to the spinal cord. 2. In suspected spinal cord injury, neurogenic shock may be prevented by carefully immobilizing the patient to prevent further damage to the spinal cord. 3. Support CV and neurologic function until the usually transient episode of neurogenic shock resolves. Applying elastic compression stockings and elevating the foot of the bed may minimize the pooling of blood in the legs 4. Administration of heparin or LMWH (Lovenox) as prescribed, application of elastic compression stockings, or use of pneumatic compression of the legs may prevent thrombus formation. 5. Passive ROM of the immobile extremities helps promote circulation.

Anaphylactic Shock
occurs rapidly and is life-threatening. Because anaphylactic shock occurs in patients already exposed to an antigen and who have developed antibodies to it, it can often be prevented

It is caused by a severe allergic reaction when patients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigenantibody reaction.

Medical Management
1. removal of the causative antigen 2. Epinephrine is given for its vasoconstrictive effect. 3. Diphenhydramine (Benadryl) is administered to reverse the effects of histamine, thereby reducing capillary permeability. 4. Nebulized medications such as albuterol (Proventil), may be given to reverse histamine-induced bronchospasm. 5. If cardiac and respiratory arrests are imminent or have occurred, CPR is performed. Endotracheal intubation or tracheotomy may be necessary to establish an airway. 6. IV lines are inserted to provide access for administering fluids and medications. Nursing Management: assess patient for allergies or previous reactions to antigens (e.g., medications, blood products, foods, contrast agents, latex) and communicate the existence of allergies or reactions to others.