Clinical emergencies-

Medical Surgical Nursing

Mrs.Mamta Toppo
Assoc.Professor
RIMSCON
Concept of Emergency Nursing
 • The term emergency is used for those
patients who require immediate action
to prevent further deteriorations or
stabilizing the condition till the
availability of the services close to the
patients.
Principles of Emergency Nursing
 • Establish a patent airway and provide
 adequate ventilation.
 • Control haemorrhage, prevent and manage
shock.
 • Maintain and restore effective circulation
 • Evaluate the neurological status of the client
 • Carry out a rapid initial and ongoing physical
assessment
Principles of Emergency Nursing Cont…

 • Start cardiacmonitoring
 • Protect and clean wounds
 • Identify significant medical history
and allergies
 • Document the findings in medical
records.
Scope of Emergency Nursing

 • To provide immediate action to treat the

patient
 • For crisis intervention
 • To treat emergency condition
irrespective of age group
 • To treat a wide variety of illness or
injury situations, ranging from sore
throat to a heart attack
Principles of Emergency management
and Emergency medical services
 • Early detection
 • Early reporting
 • Early response
 • Good on scene care
 • Care during transportation
 • Transport to definitive care
General Principles of Emergency
medical care
 • Triage
 • Primary survey using ABCD approach
 – Airway, Breathing , Circulation and
Disability
 • Secondary survey using EFGHI approach
 – Exposure to environment
 – Full set of vital signs
 – Give comfort measures
 – History collection
 – Inspect the posterior surface
General Principles of Emergency
medical care

 • Secondary survey using AMPLE

approach
 – Allergy
 – Medication history
 – Past health history
 – Last meal
 – Events/ Environment preceding illness
or injury
MEDICAL 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
Diagnostic tests.
 Assess for Pain
Abdominal X-ray
 Nausea, vomitting,
CBC
 Diarrhoea, Constipation,
Flatulence Urine analysis.

Ultra sound
 Fatigue, Fever,
 Increase abdominal CT scan
girth.

 Board like abdomen

 NURSING - Physical Assessment

Vital • Tachycardia - volume loss ( Shock)

Signs
• Rapid shallow breathing- Peritonitis

• Auscultate before palpating

Bowel • Absent sounds- possible peritonitis,
sounds shock
• High pitched tinkling sounds - Possible
bowel obstruction

Position and
general
• Still refusing to move - inflammation or
appearance 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

 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
Causes of Shock
Medical Surgical

 MI Post op bleeding

 Dehydration GI bleeding

 Sepsis Aortic dissection
 Diabetes Insipidus
Ruptured Ectopic
 Addisonian crisis
pregnancy
Trauma Ruptured organ or
 Fracture
vessel
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 Cardiac Cardiogenic

infarction tamponade shock

Sudden
Pulmonary
cardiac
embolism
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 management
Maintain 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 management
Monitor 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
•Initial Exam

•Body position , Skin signs and color, Respiratory

rate and effort, Mental status , Pulse (rate &

character)
• Onset
Focused Exam (S)
• Provocation
Signs and symptoms • Quality
Allergies (med allergies) • Radiation
Medications • Severity
Past medical history
• Time
Last meal or intake
Events leading to call
Diagnostic tests
Physical examination

Pulse oxymetry

ABG

X-ray

PFT

CT/MRI
Tension  Needle decompression
Pneumo
 Place Flutter valve
thorax
Prepare for chest tube
insertion.

 Surgical management –
Thoracotomy
Open  Observe for the development of tension
Pnuemo- pneumothorax
thorax  Cover the wound with an 3 sided occlusive
dressing
 Asherman
Chest seal
Airway
 Simultaneous protection of the C-spine .
obstruction
 ETT or Nasotracheal tube intubation
 Tracheostomy and Cricothyrotomy
 Epinephrine administration
 Cardiopulmonary resuscitation (CPR)

Status • Correct Hypovolemia and mechanical

Asthmatics
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 Aids
History 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
Assessment
Secondary Survey
Primary Survey

 ABCDEs of trauma care

AMPLE history
A - Airway
Physical exam
B - Breathing

C - Circulation
Reassessment of

D - Disability vitals

E – Exposure
Diagnostic studies
Nursing- Assessment
Breathing

Unlaboured Laboured No breathing

Beware
Pneumothorax
Chest injury Contusion Head injury
Flial chest Spinal 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 Management
Assess 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.
• Dizziness.
Nausea or vomiting.
Chest
Irregularorpupil
abdominalpain
size.

Changes in consciousness.
Burning or tearing
eyes.
Seizures.Headache.Dizziness

Irregular
Sweating. pupil sizes
Burning and tearing eyes
 Abnormal skin color.
Abnormal skin color ,Sweating
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
Diagnosis
Acute pain

Decreased cardiac output

Inability to sustain spontaneous ventilation

Ineffective breathing pattern

Impaired gas exchange

Impaired tissue perfusion

Deficient Fluid volume