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Table 6-44

Condition	Assessment: Signs and Symptoms	Prehospitalization Nursing Care	In-hospital Nursing Care
Cardiovascular Emergencies
Myocardial infarction—ischemia and necrosis of cardiac muscle secondary to insufficient or obstructed coronary blood flow	Prehospital: Chest pain: viselike, choking, unrelieved by rest or nitroglycerin Skin: ashen, cold, clammy Vital signs: pulse—rapid, weak, thready; increased rate and depth of respirations; dyspnea Behavior: restless, anxious In hospital: C/V: blood pressure and pulse pressure decreased Heart sounds: soft; S3 may be present Respirations: fine basilar crackles Laboratory: ECG consistent with tissue necrosis (Q waves) and injury (ST-segment elevation ); serum enzymes elevated (CK-MB, troponin)	If coronary suspected, call physician, paramedic service, or emergency ambulance Calm and reassure client that help is coming Place in semi-Fowler’s position Keep client warm but not hot	Rapidly assess hemodynamic and respiratory status Place on cardiac monitor to determine treatment Place on O2 Start IV as ordered—usually D5W per microdrip to establish lifeline for emergency drug treatment Relieve pain—morphine SO4 IV as needed, aspirin, nitroglycerin Draw blood for electrolytes, enzymes, as ordered Take 12-lead ECG Once client is stable, transfer to coronary care unit (CCU)
Cardiac arrest—cardiac standstill or ventricular fibrillation secondary to rapid administration or overdose of anesthetics or narcotic drugs, obstruction of the respiratory tract (mucus, vomitus, foreign body), acute anxiety, cardiac disease, dehydration, shock, electric shock, or emboli	Cyanosis, gasping Respirations: rapid, shallow, absent Pulse: weak, thready, >120 beats/min, absent Muscle: twitching Pupils: dilated Skin: cold, clammy Loss of consciousness	CPR Position: flat on back Check for no breathing or no normal breathing (only gasping) while checking for unresponsiveness Activate the emergency response system: call 9-1-1. Get automated external defibrillator (AED) or send someone else to get; use within 5 min Take 10 sec to check pulse If no pulse, begin chest compressions—30 compressions at a rate of 100/min. Depress sternum at least 2 inches After 30 compressions, open airway and give 2 breaths (CAB—compressions, airway, breathing) within 10 sec Use AED when available	If monitored, note rhythm; call for help and note time Immediate countershock if rhythm is ventricular fibrillation or ventricular tachycardia If countershock unsuccessful, begin CPR, as in prehospital care
		No heartbeat: One-or two-person lay rescuer CPR: 100 chest compressions per minute, with two rescue breaths between every 30 compressions (no difference in ratio for one or two persons); Check pulse at neck after 5 cycles or 2 min Provide early defibrillation with AED within 5 min of arrest if indicated If heartbeat returns: assist respiration and monitor pulse; continue CPR until help arrives	Two-person rescue First person: begins CPR as described in prehospital care Second person: Pages arrest team Brings defibrillator to bedside and countershocks, if indicated by rhythm; defibrillate within 3 min of arrest if indicated Brings emergency cart to bedside Suctions airway, if indicated due to vomitus or secretions Bags client with 100% O2 Assists with intubation when arrest team arrives Establishes intravenous line if one is not available
Shock—cellular hypoxia and impairment of cellular function secondary to: trauma, hemorrhage, fright, dehydration, cardiac insufficiency, allergic reactions, septicemia, impairment of nervous system, poisons	Early shock Sensorium: conscious, apprehensive, and restless; some slurring of speech Pupils: dull but reactive to light Pulse: rate <140/min; amplitude full to mildly decreased Blood pressure: normal to slightly decreased Neck veins: normal to slightly flat in supine position; may be full in septic shock or grossly distended in cardiogenic shock Skin: cool, clammy, pale Respirations: rapid, shallow GI: nausea, vomiting, thirst Renal: urine output 20–40 mL/hr	Check breathing—clear airway if necessary; if no breathing, give artificial respirations; if breathing is irregular or labored, raise head and shoulders Control bleeding by placing pressure on the wound or at pressure points (proximal artery) Make comfortable and reassure Cover lightly to prevent heat loss, but do not bundle up If neck or spine injury is suspected—do not move, unless victim in danger of more injury	Check vital signs rapidly—pulse, pupils, respirations Check airway; clear if necessary; draw ABGs; PO2 should be maintained above 60 mm Hg; elevated PCO2 indicates need for intubation and ventilatory assistance Control gross bleeding Prepare for insertion of intravenous line and central lines—if abdominal injuries present Peripheral line should be placed in upper extremity if fluids being lost in abdomen
		If client unconscious or has wounds of the lower face and jaw—place on side to promote drainage of fluids; position client on back unless otherwise indicated	Draw blood for specimens: Hgb, Hct, CBC, glucose, CO2, sodium amylase, BUN, K+; type and cross-match, blood gases, CPK-MB, troponin, prothrombin times Prepare infusion of crystalloid replacement—NS usual choice; may include Ringer’s lactate or half-normal saline
	Severe or late shock Sensorium: confused, disoriented, apathetic, unresponsive; slow, slurred speech, often incoherent Pupils: dilating, dilated, slow or nonreactive to light Pulse: rate >150 beats/min, thready, weak Blood pressure: 80 mm Hg or unobtainable Neck veins: flat in a supine position—no filling; full to distended in septic or cardiogenic shock Skin: cold, clammy, mottled; circumoral cyanosis, dusky, cyanotic Eyes: sunken—vacant expression Renal: urine output <20 mL/hr	Raise feet 6–8 inches unless client has head or chest injuries; if victim becomes less comfortable, lower feet If client complains of thirst, do not give fluids unless client is more than 6 hr away from professional medical help; under no conditions give water to clients: who are unconscious, having seizures or vomiting, appearing to need general anesthetic, or with a stomach, chest, or skull injury Be calm and confident; reassure client help is on the way	Assess and intervene as for early shock; then obtain information as to onset and past history. Treat underlying cause STAT. Catheterize and monitor client urine output as ordered Take 12-lead ECG Insert nasogastric tube and assess aspirate for volume, color, and blood; save specimen if poison or drug overdose suspected If CVP low (12)—infuse 200–300 mL over 5–10 min. If CVP rises sharply—fluid restriction necessary; if remains low—hypovolemia present If client febrile—blood cultures and wound cultures will be ordered If urine output scanty or absent—give mannitol as ordered If systolic BP <90 mm Hg—give vasopressors (Levophed, vasopressin)
Respiratory Emergencies
Choking—obstruction of airway secondary to aspiration of a foreign object	Gasping, wheezing; looks panicky, but can still breathe, talk, cough Cough: weak, ineffective; breathing sounds like high-pitched crowing; Color—white, gray, blue Difficulty speaking; clutches throat	Do not interfere if coughing; do not slap on back; watch closely; call for assistance Victim standing/sitting and conscious: Perform obstructive airway maneuver(formerly called Heimlich maneuver): stand behind victim, wrap arms around waist, place fist against abdomen, and with your other hand, press it into the victim’s abdomen with a quick upward thrust until the obstruction is relieved or the victim becomes unconscious Victim lying down: Roll the victim onto his or her back; straddle the victim’s thighs; place heel of hand in the middle of abdomen; place other hand on top of the first; stiffen arms and deliver 6–10 abdominal thrusts Unconscious victim: Lay rescuers—proceed to CPR. No abdominal thrusts or blind finger sweeps EMS responders—Try to ventilate; if unsuccessful, deliver abdominal thrusts using technique described for obstructive airway; probe mouth for foreign objects; keep repeating above procedure until ventilation occurs; as victim becomes more deprived of air, muscles will relax and maneuvers that were previously unsuccessful will begin to work; when successful in removing obstruction, give two breaths; check pulse; start CPR if indicated On obese or pregnant victims—use chest thrusts instead of abdominal thrusts You are victim and alone: Place your two fists for abdominal thrusts; bend over back of chair, sink, etc. and exert hard, repeated pressure on abdomen to force object up; push fingers down your throat to encourage regurgitation	As in prehospital care; when probing mouth for foreign object, turn head to side, unless client has neck injury; in event of neck injury, raise the arm opposite you and roll the head and shoulders as a unit, so that head ends up supported on the arm
Acute respiratory failure—sudden onset of an abnormally low PaO2 (<60 mm Hg) or high PCO2 (>60 mm Hg) secondary to: lung disease or trauma, peripheral or central nervous system depression, cardiac failure, severe obesity, airway obstruction, environmental abnormality	Hypoxia Sensorium: acute apprehension Respiration: dyspnea; shallow, rapid respirations Skin: circumoral cyanosis; pale, dusky skin and nailbeds C/V: slight hypertension and tachycardia, or hypotension and bradycardia Hypercapnia Sensorium: decreasing mentation; headache Skin: flushed, warm, moist C/V: hypertension; tachycardia	If you suspect respiratory distress, call physician; calm and reassure client; place in a chair or semisitting position; keep warm but not hot; phone for ambulance; if respirations cease or client becomes unconscious: clear airway and commence respiratory resuscitation; check pulse: initiate CPR if necessary; continue resuscitation until help arrives	Check client’s ability to speak; maintain airway by placing in high Fowler’s position; check vital signs: BP, pulse rate and rhythm, temperature, skin color, rate and depth of respirations; place on O2, pulse oximetry, STAT ABG Prepare for intubation if: Client has flail chest Client is comatose without gag reflex Client has respiratory arrest; open airway, ambu bag with 100% O2 via face mask until intubation PaCO2 >55 mm Hg PaO2 <60 mm Hg FiO2 >50% using nasal cannula, catheter, or mask Respiratory rate >36 After intubation: Check bilateral lung sounds Observe for symmetrical lung expansion Maintain humidified oxygen at lowest Fi O2 possible to achieve PaO2 of 60 mm Hg Monitor exhaled CO2 with caprometer. Improve ventilation (decrease P CO2) by: Frequent suctioning—oral and above cuff of ET tube IPPB indicated if tidal volume decreases Administer drugs as ordered: sympathomimetics, xanthines, antibiotics, and steroids Monitor: arterial blood gases, electrolytes, Hct, Hgb, and WBCs Bronchoscopy may be indicated for thick, tenacious secretions Do not: Administer sedatives Correct acid-base problems without monitoring electrolytes Overcorrect PaCO2 Leave client alone while oxygen therapy is initiated. Once client is stable, transfer to ICU
Near-drowning—asphyxiation or partial asphyxiation due to immersion or submersion in a fluid or liquid medium	Conscious victim: Acute anxiety, panic; increased rate of respirations Pale, dusky skin	Conscious victim: Try to talk victim out of panic so can find footing and way to shore Utilize devices such as poles, rings, clothing to extend to victim; do not let victim who is panicked grab you; do not attempt swimming rescue unless specially trained If you suspect head or neck injury—handle carefully, floating victim back to shore with body and head as straight as possible; do not turn head or bend back	Nonsymptomatic near-drowning victim: Draw blood for arterial blood gases with client breathing room air PA and lateral chest x-ray Auscultate lungs Admit to hospital for further evaluation if: PaO2 <80 mm Hg pH <7.35 Pulmonary infiltrates present, or auscultation reveals crackles Victim inhaled fluids containing: choline, hydrocarbons, sewage, or hypotonic or freshwater
	Unconscious victim: Shallow or no respirations Weak or no pulse	Unconscious victim: If victim not breathing: as soon as you have firm support, begin resuscitation Tilt head back, bring jaw forward, pinch nostril shut, give two quick breaths On shore: Check breathing Lay victim flat on back; cover and keep warm Calm and reassure victim Do not give food or water Get to medical assistance as soon as possible If unconscious and not breathing: begin sequence for CPR; compress water from abdomen only if interfering with ventilation attempts If airway obstructed: reposition head; attempt to ventilate; if EMS responder: perform 6–10 abdominal thrusts; sweep mouth deeply; attempt to ventilate; repeat until successful Once ventilation established, check pulse; if absent, begin chest compressions as in CPR, one-person or two-person rescue Continue CPR until victim revives or help arrives If victim revives, cover and keep warm; reassure victim help is on the way Rescue personnel can further assist emergency department personnel by: Documenting prehospital resuscitation methods used Immobilizing victims suspected of cervical spine injuries Using a sterile container to take a sample of immersion fluid Taking on-scene arterial blood gas sample for later analysis	Symptomatic near-drowning victim: Provide basic or advanced cardiac life support Provide clear airway and adequate ventilation by: Suctioning airway Inserting artificial airway and attaching it to ventilator as indicated Inserting nasogastric tube to suction to minimize aspiration of vomitus Monitor ECG continuously Start IV infusion D5W at keep-open rate for freshwater near-drowning; D5NS in saltwater near-drowning Assist with insertion of CVP and pulmonary artery (PA) catheter to guide subsequent infusion rates  Administer drugs as ordered: anticonvulsants; steroids, antibiotics, stimulants, antiarrhythmics Provide rewarming if hypothermia present Insert Foley to assess kidney function because freshwater near-drowning causes renal tubular necrosis due to RBC hemolysis Transfer to ICU when stabilized
Systemic Injuries
Multiple traumas	Sensorium: alert; disoriented, stuporous, comatose Respirations: increased rate, depth; shallow; asymmetrical; paradoxical breathing; mediastinal shift; gasping, blowing C/V: signs of shock (see Physiological Integrity, 544–545) Abdomen: contusions; pain; abrasions; open wounds; rigidity; increasing distention Skeletal system: pain; swelling; deformity; inappropriate or no movement Neurological: pupils round, equal, react to light; ipsilateral dilation and unresponsive; fixed and dilated bilaterally Bilateral movement and sensation in all extremities Progressive contralateral weakness Loss of voluntary motor function See Sensorium (above) for level of consciousness	Do not move client unless you must, to prevent further injury; send for help Check breathing—give mouth-to-mouth resuscitation if indicated Check for bleeding Control bleeding by applying pressure on wound or on pressure points (artery proximal to wound) Use tourniquet only if above pressure techniques fail to stop severe bleeding Check for shock (pulse, pupils, skin color) and other injuries Fractures: keep open-fracture area clean Do not try to set bone If client must be moved—splint broken bones with splints that extend past the limb joints; tie splints on snugly but not so tight as to cut off circulation Check peripheral pulses If head or back injury suspected—keep body straight; move only with help Reassure client that help is on the way	Assess vital functions; ECG monitoring, continuous pulse oximetry Establish airway; ventilate with ambu bag, ventilator Draw arterial blood gases Control bleeding Prepare infusions of blood, crystalloids Assess for other injuries: head injuries—suspect cervical neck injury with all head injuries Place sandbags to immobilize head and neck Do mini-neurological examination: level of consciousness, pupils, bilateral movement, and sensation Get history—time of injury; any loss of consciousness; any drug ingestion Stop bleeding on or about head Apply ice to contusions and hematomas Check for bleeding from nose, pharynx, ears Check for cerebrospinal fluid from ears or nose Assist with spinal tap if ordered Keep accurate I&O Protect from injury if restless, seizures; orient to time, place, person Administer steroids, diuretics, as ordered Check for signs of increasing intracranial pressure: slowing pulse and respiration, widened pulse pressure, decreasing mentation
Spinal injuries			Assess and support vital functions as above Immobilize—no flexion or extension allowed If in respiratory distress—nasotracheal intubation or tracheostomy to avoid hyperextending neck Check for level of injury and function, asking client to: Lift elbow to shoulder height (C5) Bend elbow (C6) Straighten elbow (C7) Grip your hand (C8-T1) Lift leg (L3) Straighten knee (L4, L5) Wiggle toes (L5) Push toes down (S1) If client is comatose: Rub sternum with knuckles If all extremities move, severe injury unlikely If one side moves and other does not, potential hemiplegia If arms move and legs do not, lower spinal cord injury Administer steroids as ordered Assist with application of skull tongs—Vinke or Crutchfield Maintain IV infusions Insert Foley as indicated Assist with dressing of open wounds
Chest injuries			Note color and pattern of respirations, position of trachea Auscultate lungs and palpate chest for: crepitus, pain, tenderness, and position of trachea Place gauze soaked in petroleum jelly, if available, over open pneumothorax (sucking chest wound) to seal hole and decrease respiratory distress Assist with tracheostomy if indicated Prepare for insertion of chest tubes if pneumothorax or hemothorax present
Abdominal injuries			Observe for rigidity Check for hematuria Auscultate for bowel sounds Assist with paracentesis to confirm bleeding in abdominal cavity Prepare for exploratory laparotomy Insert nasogastric tube—to detect presence of upper GI bleeding Monitor vital signs If organs protruding: Flex client’s knees Cover intestines with sterile towel soaked in saline Do not attempt to replace organs
Fractures			Administer tetanus toxoid as ordered Observe for pain, peripheral pulses, pallor, loss of sensation and/or movement Assist with wound cleansing, casting, x-rays, reduction Prepare for surgery if indicated Monitor vital signs
Burns—tissue trauma secondary to scalding fluid or flame, chemicals, or electricity	Superficial (first degree): Erythema and tenderness Usually sunburn	Relieve pain by applying cold, wet towel or cold water (not iced)	Cleanse thoroughly with mild detergent and water Apply gauze or sterile towel Administer sedatives and narcotics as ordered Arrange for follow-up care, or prepare for admission if burn ambulatory care impractical
	Partial thickness (second degree): Swelling, blisters; moisture due to escaping plasma	Douse with cold water until pain relieved Blot skin dry and cover with clean towel Do not : break blisters, remove pieces of skin, or apply antiseptic ointments If arm or leg burned, keep elevated Seek medical attention if second-degree burns: Cover 10% of body surface Involve hands, feet, or face	Check tetanus immunization status Administer sedatives or narcotics as ordered Assess respiratory and hemodynamic status; oxygen or ventilatory assist as indicated, intravenous infusions as ordered to combat shock Remove all clothing from burn area Using aseptic technique, cleanse burns as indicated
	Full thickness (third degree): White, charred areas	Do not remove charred clothing Cover burned area with clean towel, sheet Elevate burned extremities Apply cold pack to hand, face, or feet Sit client up with face or chest wound to assist respirations Maintain airway Observe for shock Do not: Put ice water on burns or immerse wounds in ice water—may increase shock Apply ointment Calm and reassure victim Get medical help promptly If client conscious, not vomiting, and medical assistance is more than 6 hr away: may give sips of weak solution of salt, soda, and water	Do not break blebs or attempt débridement Assist with application of dressings as ordered Maintain frequent checks of vital signs, urine output Provide psychological support—explain procedures, orient, etc. Assist with application of splints as ordered  Administer tetanus immune globulin or toxoid as ordered Assist with transfer to hospital unit
	Fourth degree: Black	Same as full thickness.
	Chemical burns	Flush with copious amounts of water Get rid of clothing over burned area	Flush with copious amounts of water Administer sedation or narcotics as ordered
	Burns of the eye: Acid	Flush eye with water for at least 15 min Pour water from inside to outside of eye to avoid contaminating unaffected eye Cover—seek medical attention at once	Irrigate with water: never use neutralizing solution Instill 0.5% tetracaine as ordered Apply patch
	Alkali (laundry detergent or cleaning solvent)	Do not allow client to rub eye Flush eye with water for at least 30 min Cover—seek medical attention at once	As above for acid
Abdominal Emergencies
Aortic aneurysm—rupture or dissection	Primarily men >age 60 Sudden onset of excruciating pain: abdominal, lumbosacral, groin, or rectal Orthopnea, dyspnea Fainting, hypotension; if dissecting, marked hypertension may be present Palpable, tender, pulsating mass in umbilical area Femoral pulse present; dorsalis pedis—weak or absent	Notify physician Lay client flat, or raise head if in respiratory distress Cover to keep warm but not hot Institute shock measures (see Physiological Integrity) Calm; reassure that help is on the way.	Assess respiratory and hemodynamic status Institute shock measures (see Physiological Integrity) if indicated Evaluate and compare peripheral pulses Assist with x-rays Assist with emergency preoperative treatment
Blunt injuries—spleen	Left upper quadrant pain, tenderness and moderate rigidity; left shoulder pain ( Kehr’s sign ) Hypotension; weak, thready pulse; increased respirations (shock)	Lay client flat Institute shock measures (see Physiological Integrity).	Assess respiratory and hemodynamic status Maintain airway and ventilation as indicated Institute infusions of colloid or crystalloids as ordered Insert both CVP and arterial monitoring lines Insert Foley catheter Prepare for splenectomy
Eye and Ear Emergencies
Chemical burns	See Burns, Physiological Integrity	See Burns	See Burns
Blunt injuries secondary to flying missiles (e.g., balls, striking face against car dashboard)	Decreased visual acuity, diplopia, blood in anterior chamber Pain, conjunctiva reddened, edema of eyelids	Prevent victim from rubbing eye Cover with patch to protect eye Seek medical help immediately	Test visual acuity of each eye using Snellen or Jaeger chart Assist with fluorescein administration—to facilitate identifying breaks in cornea
Sharp ocular trauma—secondary to small or larger foreign bodies	Reports feeling as if something were hitting eye Pain, tearing, reddened conjunctiva Blurring of vision Foreign object may be visible	Keep victim from rubbing eye Cover very lightly—do not apply pressure	Check visual acuity in both eyes Check pupils Instill 1% tetracaine HCl as ordered to relieve pain Administer antibiotic drops or ointment as ordered Apply eye patch Provide instructions for subsequent care and follow-up
Foreign bodies in ears—beans, peas, candy, foxtails, insects	Decreased hearing; pulling, poking at ear and ear canal; buzzing, discomfort	Do not attempt to remove object Seek medical assistance	Inspect ear canal Assist with sedating (especially children)—restraint may be necessary Assist with procedures to remove object: Forceps or curved probe for foxtails, irregularly shaped objects 10F or 12F catheter with tip cut squarely off and attached to suction to remove round object Irrigate external auditory canal to flush out insects, materials that do not absorb water; do not irrigate if danger of perforation