NurseReview.Org Emergency Nursing & Critical Care

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1. Slide 1: Emergency and Critical Care Nurse Licensure Examination Review
2. Slide 3: Basic life support (BLS) A means of providing oxygen to  the brain, heart and other organs until help arrives Also known as  CARDIOPULMONARY RESUSCITATION
3. Slide 4: Basic life support (BLS) An adult is a person above age 8  A child is any person age 1 to 8  years old An infant is anyone under 1 year 
4. Slide 5: Basic life support (BLS) The BLS follows the A-B-C  principle • A= airway • B= breathing • C= circulation
5. Slide 6: Basic life support (BLS) Causes of cardiac arrest  • Respiratory arrest • Direct injury • Drug overdose • Cardiac arrhythmias
6. Slide 7: Basic life support (BLS) ADULT STEPS in CPR: First STEP!!!  • ASSESSMENT: determine Unresponsiveness • Assess for 5-10 seconds • Shake the victim’s shoulder and ask: “are you okay”
7. Slide 8: Basic life support (BLS) ADULT STEPS in CPR: Second Step  • Survey the area
8. Slide 9: Basic life support (BLS) ADULT STEPS in CPR: Third Step  • Call for HELP • Activate emergency medical system • Note: for child and infant this is done LAST
9. Slide 10: Basic life support (BLS) ADULT STEPS in CPR: Fourth step  • Place Victim in Supine position on a flat firm surface • Log roll the patient when moving
10. Slide 11: Basic life support (BLS) ADULT STEPS in CPR: Fifth step  • OPEN the airway • Head tilt-Chin Lift method • Jaw thrust maneuver if neck injury is suspected
11. Slide 13: Basic life support (BLS) ADULT STEPS in CPR: Sixth step  • Assess BREATHING Place ear over the nose and mouth   Look for chest movement  Perform for 3-5 SECONDS
12. Slide 14: Basic life support (BLS) ADULT STEPS in CPR: Sixth step  • Assess BREATHING If breathing: place on side if no  neck injury; DO NOT move if with neck injury If NOT BREATHING: deliver  INITIALLY 2 rescue breath via mouth to mouth  Then deliver 10-12 breaths/minute
13. Slide 15: Basic life support (BLS) ADULT STEPS in CPR: Seventh step  • Assess CIRCULATION Check for the carotid pulse on the  side close to you for 5-10 SECONDS  If with (+) pulse ; continue giving 10-12 breaths/minute
14. Slide 16: Basic life support (BLS) ADULT STEPS in CPR: Seventh step  • Assess CIRCULATION If withOUT pulse: START Chest  Compression  Correct hand placement: LOWER HALF of sternum one hand over the other with fingers interlacing  Depress: 1 ½ to 2 INCHES 80-100 compressions/min
15. Slide 17: Basic life support (BLS) ADULT STEPS in CPR: Seventh step  • Assess CIRCULATION If withOUT pulse: START Chest  Compression  ONE-rescuer: 15 chest: 2 breaths TWO-rescuer: 5 chest: 1 breath  DO FOUR cycles and re-assess for pulse 
16. Slide 18: Basic life support (BLS) CHILD 1-8 years old  AIRWAY: assess unresponsiveness and keep airway patent by HTCL or JT  BREATHING: assess for airflow and chest movement • If breathing: maintain patent airway • If NOT breathing : deliver 2 rescue breaths by mouth to mouth • DELIVER 20 breaths/minute
17. Slide 19: Basic life support (BLS) CHILD 1-8 years old  CIRCULATION: assess the carotid pulse • If with pulse: continue to deliver 15-20 breaths/minute • If WITHOUT pulse: start chest compression • Correct hand placement: lower half of sternum using heel of ONE HAND • DELIVER: 1 to 1 ½ inches 80- 100 chest compressions/min 5:1 (do 20 cycles  EMS)
18. Slide 20: Basic life support (BLS) INFANT Less than 1  Determine unresponsiveness  AIRWAY: Place head of infant in NEUTRAL position  BREATHING: assess for rise-fall of chest and airflow • If breathing: maintain patent airway • If NOT breathing: initiate 2 rescue breathing via mouth to mouth and nose • DELIVER 20 breaths/min SLOWLY
19. Slide 21: Basic life support (BLS) INFANT Less than 1 CIRCULATION: assess for pulse: The  BRACHIAL pulse is utilized!! • If with pulse: continue to deliver 20 breaths/min • If WITHOUT pulse, start chest compression • Correct hand placement: just below the nipple line in the sternum using 2-3 fingers of one hand!! • DELIVER: ½ to 1 inch depth 100 chest com/min 5:1 ratio (do 20 cycles EMS)
20. Slide 22: AIRWAY Obstruction Incomplete  • Crowing sound is heard encourage to cough Complete  • Clutching of the neck • Ask: “Are you choking?” • Perform Heimlich’s
21. Slide 23: AIRWAY Obstruction Complete  • If patient becomes unconscious: Place supine on flat surface   Perform tongue-jaw lift maneuver  FINGERSWEEP to remove object  Open airway and attempt ventilation  Perform Heimlich while supine  Reattempt ventilation  SEQUENCE: TJL finger-sweep rescue breaths Heimlich’s TJL
22. Slide 24: AIRWAY Obstruction Pediatric considerations:   CHILD: NEVER DO Blind Finger sweep
23. Slide 25: AIRWAY Obstruction Pediatric considerations:   INFANT: never DO blind finger- sweep  Give five back blows in the interscapular area and turn the infant with head lower than trunk then deliver chest thrust below the nipple line
24. Slide 26: AIRWAY Obstruction Obstetric considerations:   Hand is placed over the middle part of sternum: backward chest thrust If unconscious: place pillow  below the RIGHT abdomen to displace uterus
25. Slide 27: Shock An abnormal physiologic state  where an imbalance exists between the amount of circulating blood volume and the size of the vascular bed.
26. Slide 29: Pathophysiology of Shock 1. Cellular effects of shock  In the absence of oxygen, the cell will undergo Anaerobic metabolism to produce energy source and with it comes numerous by-products like lactic acid  The cell will swell due to the influx of Na and H20, mitochondria will be damaged, lysosomal enzymes will be liberated, and then cellular death ensues.
27. Slide 30: Pathophysiology of Shock 2. Organ System Responses  When the patient encounters precipitating causes of shock, the circulatory function diminishes there is decreased cardiac output  Hypotension and decreased tissue perfusion will result
28. Slide 31: Shock Stages There are three stages of shock  Compensatory stage  Progressive stage  Irreversible stage
29. Slide 32: Shock Stages THE COMPENSATORY STAGE OF SHOCK  In this stage, the patient’s blood pressure is within normal limits.  Patient’s blood is shunted from the kidney, skin and GIT to the vital organs- brain, liver and muscles  Manifestations of cold clammy skin, oliguria and hypoactive bowel sounds can be assessed.  Medical management includes IVF and medication  Nursing management includes monitoring of tissue perfusion & vital signs, reduction of anxiety, administering IVF/ordered medications and promotion of safety
30. Slide 33: THE PROGRESSIVE STAGE OF SHOCK  In this stage, the mechanisms that regulate blood pressure can no longer compensate and the mean arterial pressure falls.  The overworked heart becomes dysfunctional. Heart rate becomes very rapid (as high as 150 bpm)  Blood flow to the brain becomes impaired, the mental status deteriorates due to decreased cerebral perfusion and hypoxia.  Laboratory findings will reveal increased BUN and Creatinine. Urinary output decreases to below 30 mL/hour.
31. Slide 34: Shock Stages THE PROGRESSIVE STAGE OF SHOCK  Decreased blood flow to the liver impairing the hepatic functions. Toxic wastes are not metabolized efficiently, resulting to accumulation of ammonia, bilirubin and lactic acids.  The reduced blood flow to the GIT causes stress ulcers and increased risk for GI bleeding.  Hypotension, sluggish blood flow, metabolic acidosis (due to accumulation of lactic acid), and generalized hypoxemia can interfere with normal blood function.
32. Slide 35: Shock Stages THE IRREVERSIBLE STAGE OF SHOCK  This stage represents the end point where there is severe organ damage that patients do not respond anymore to treatment. Survival is almost impossible to maintain.  Despite treatment, the BP remains low, anaerobic metabolisms continues and multiple organ failure results.  Medical management is the use of life supporting drugs like epinephrine and investigational medications.
33. Slide 36: Assessment of Shock Assessment Findings Skin : Cool, pale, moist in hypovolemic and cardiogenic shock : Warm, dry, pink in septic and neurogenic shock Pulse  Tachycardia, due to increased sympathetic stimulation  Weak and thready Blood pressure  1. Early stages: may be normal due to compensatory mechanisms  2. Later stages: systolic and diastolic blood pressure drops.
34. Slide 37: Assessment of Shock Assessment Findings Respirations: rapid and shallow, due to tissue anoxia and excessive amounts of CO (from metabolic Acidosis) Level of consciousness: restlessness and apprehension, progressing to coma Urinary output: decreases due to impaired renal perfusion Temperature: decreases in severe shock (except septic shock).
35. Slide 38: Management of Shock Nursing Interventions  Management in all types and phases of shock includes the following: Basic life support   Fluid replacement  Vasoactive medications  Nutritional support
36. Slide 39: Management of Shock A. Maintain patent airway and adequate ventilation. B. Promote restoration of blood volume; administer fluid and bloodreplacement as ordered C. Administer drugs as ordered D. Minimize factors contributing to shock. E. Maintain continuous assessment of the client. F. Provide psychological support: reassure client to relieve apprehension, and keep family advised G. Provide Nutritional support
37. Slide 41: Hypovolemic Shock This is the MOST common form of shock characterized by a decreased intravascular volume Risk factors: external Fluid Losses Trauma, Surgery, Vomiting, Diarrhea, Diuresis, DI Risk factors: internal fluid shifts Hemorrhage, Burns, Ascites, Peritonitis, Dehydration
38. Slide 42: Hypovolemic Shock Decreased blood volume  decreased venous return to the heart decreased stroke volume decreased cardiac output decreased tissue perfusion  Assessment findings: cold clammy skin, tachycardia, mental status changes, tachypnea
39. Slide 43: Hypovolemic Shock MEDICAL MANAGEMENT:  • The major medical goals are to restore intravascular volume, to redistribute the fluid volume, and to correct the underlying cause of fluid loss promptly
40. Slide 44: Hypovolemic Shock NURSNG MANAGEMENT:  • Primary prevention of shock is the most important intervention of the nurse. • General nursing measures include- safe administration of the ordered fluids and medications, documenting their administration and effects. The nurse must monitor the patient for signs of complications and response to treatment. Oxygen is administered to increase the amount of O2 carried by the available hemoglobin in the blood.
41. Slide 45: Cardiogenic shock This shock occurs when the heart’s ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues  Risk factors: Coronary factor- Myocardial infarction  Risks factors: NON coronary: • Cardiomyopathies • Valvular damage • Cardiac tamponade • Dysrhythmias
42. Slide 46: Cardiogenic shock Precipitating factors will cause  decreased cardiac contractility Decreased stroke volume and cardiac output leading to 3 things:  Damming up of blood in the pulmonary vein will cause pulmonary congestion  Decreased blood pressure will cause decreased systemic perfusion  Decreased pressure causes decreased perfusion of the coronary arteries leading to weaker contractility of the heart
43. Slide 47: Cardiogenic shock ASSESSMENT FINDINGS: Angina, hemodynamic instability, dysrhythmias MEDICAL MANAGEMENT:  • The goals of medical management are to limit further myocardial damage and preserve and to improve the cardiac function by increasing contractility. NURSING MANAGEMENT:  • The nurse prevents cardiogenic shock by early detection of patients at risk. • Safety and comfort measures like proper positioning, side-rails, and reduction of anxiety, frequent skin care and family education.
44. Slide 48: Circulatory shock This is also called distributive  shock. It occurs when the blood volume is abnormally displaced in the vasculature. • Septic Shock • Neurogenic Shock • Anaphylactic Shock
45. Slide 49: Circulatory shock Massive arterial and venous  dilation allows pooling of blood peripherally maldistribution of blood volume decreased venous return decreased stroke volume  decreased cardiac output Decreased blood pressure decreased tissue perfusion.
46. Slide 50: Circulatory shock Risk factors for Septic Shock  • Immunosuppression • Extremes of age (<1 and >65) • Malnourishment • Chronic Illness • Invasive procedures
47. Slide 51: Circulatory shock Risk factors for Neurogenic Shock  • Spinal cord injury • Spinal anesthesia • Depressant action of medications • Glucose deficiency
48. Slide 52: Circulatory shock Risk factors for Anaphylactic Shock  • Penicillin sensitivity • Transfusion reaction • Bee sting allergy • Latex sensitivity
49. Slide 53: SEPTIC SHOCK This is the most common type of circulatory shock and is caused by widespread infection. The HYPERDYNAMIC PHASE • High cardiac output with systemic vasodilatation. • The BP remains within normal limits. • Tachycardia • Hyperthermic and febrile with warm, flushed skin and bounding pulses
50. Slide 54: SEPTIC SHOCK The HYPODYNAMIC or irreversible phase • LOW cardiac output with VASOCONSTRICTION • The blood pressure drops, the skin is cool and pale, with temperature below normal. • Heart rate and respiratory rate remain RAPID! • The patient no longer produces urine.
51. Slide 55: SEPTIC SHOCK MEDICAL MANAGEMENT:  • Current treatment involves identifying and eliminating the cause of infection. Fluid replacement must be instituted to correct Hypovolemia, Intravenous antibiotics are prescribed based on culture and sensitivity.
52. Slide 56: SEPTIC SHOCK NURSING MANAGEMENT:  • The nurse must adhere strictly to the principles of ASEPTIC technique in her patient care. • Specimen for culture and sensitivity is collected. Symptomatic measures are employed for fever, inflammation and pain. IVF and medications are administered as ordered.
53. Slide 57: Neurogenic Shock This shock results from loss of sympathetic tone resulting to widespread vasodilatation.  The patient who suffers from neurogenic shock may have warm, dry skin and BRADYCARDIA!
54. Slide 58: Neurogenic Shock MEDICAL MANAGEMENT:  • This involves restoring sympathetic tone, either through the stabilization of a spinal cord injury or in anesthesia, proper positioning.
55. Slide 59: Neurogenic Shock NURSING MANAGEMENT:  • The nurse elevates and maintains the head of the bed at least 30 degrees to prevent neurogenic shock when the patient is receiving spinal or epidural anesthesia.
56. Slide 60: Anaphylactic Shock This shock is caused by a  severe allergic reaction when a patient who has already produced antibodies to a foreign substance develops a systemic antigen-antibody reaction
57. Slide 61: Anaphylactic Shock MEDICAL MANAGEMENT:  • Treatment of anaphylactic shock requires removing the causative antigen, administering medications that restore vascular tone, and providing emergency support of basic life functions. • EPINEPHRINE is the drug of choice given to reverse the vasodilatation
58. Slide 62: Anaphylactic Shock NURSING MANAGEMENT:  • It is very important for nurses to assess history of allergies to foods and medications! • Drugs are administered as ordered and the responses to the drugs are evaluated.
59. Slide 63: Triage “trier”- to sort  To sort patients in groups based on  the severity of their health problem and the immediacy with which these problems must be addressed
60. Slide 64: Triage in the E.R. Berner’s  Emergent 2. Urgent 4. Non-urgent 6.
61. Slide 65: Triage in DISASTER! NATO  Immediate 2. Delayed 4. Minimal 6. Expectant 8.
62. Slide 66: Triage 1. Emergent • Patients have the highest priority • With life-threatening condition 2. Urgent • Patients with serious health problems • Not life-threatening, MUST be seen in 1 hour 3. Non-urgent • Episodic illness that can be addressed within 24 hours
63. Slide 67: Triage Priority Color Conditions Triage in Disaster category 1 RED Immediate Chest wounds, shock, open fractures, 2-3 burns Delayed 2 YELLOW Stable abdominal wound, eye and CNS injuries Minimal 3 GREEN Minor burns, minor fractures, minor bleeding Expectant 4 BLACK Unresponsive, high spinal cord injury
64. Slide 68: Preparing for terrorism Recognition and Awareness 1. Use of personal protective 2. equipments Decontamination of contaminants 3.
65. Slide 69: Biological Weapons ANTHRAX  Drug of choice is Ciprofloxacin or Doxycycline SMALLPOX  Supportive
66. Slide 70: Chemical Weapons Organophosphates • Supportive care • Soap and water • Atropine • Pralidoxine Cyanide • Sodium nitrite, Amyl Nitrite, Methylene Blue • Sodium thiosulfate • Hydrocobalamin
67. Slide 71: CYANIDE POISONING
68. Slide 73: Radiation Alpha Particles Cannot penetrate skin Causes local damage Beta Particles Moderately penetrate the skin Can cause skin damage and internal injury if prolonged Gamma Particles Penetrate skin Can cause serious damage X-ray is an example