NCLEX-RN: Emergency Nursing

Emergency Nursing: Shock States

Focus topic: Emergency Nursing

Definition: A syndrome in which there is insufficient circulating blood volume for the size of the vascular bed, thereby resulting in inadequate tissue perfusion and impaired cellular metabolism.

Classifications of Shock States

A. Low blood flow states.

  • Hypovolemic shock.
    a. Absolute hypovolemia—lowered intravascular volume.
    (1) Blood loss—from trauma, surgery, etc., is most common cause.
    (2) Plasma loss from burns; fluid loss from diarrhea, vomiting, etc.
    b. Relative hypovolemia—shift of fluid volume out of vascular space into extravascular space.
    (1) Etiology: pooling of fluids.
    (2) Internal bleeding or massive vasodilation.
  • Cardiogenic shock.
    a. Myocardial dysfunction that results in compromised cardiac output.
    b. Causes.
    (1) Systolic dysfunction: inability to pump blood forward.
    (2) Diastolic dysfunction: ventricles unable to adequately fill (cardiac tamponade).
    (3) Arrhythmias.
    (4) Structural abnormalities (valvular stenosis or regurgitation).

B. Maldistribution of blood flow.

  • Distribution shock is caused by massive vasodilation and pooling of blood.
  • Types of distributive shock include septic, neurogenic, and anaphylactic shock.
  • Results in decreased cardiac output.

Emergency Nursing

Emergency Nursing: Hypovolemic Shock

Focus topic: Emergency Nursing

Characteristics—Stages of Shock
A. Initial—15% volume loss: no signs/symptoms; body begins to respond to imbalance of O2 supply and demand.
B. Compensatory or second stage—volume loss increases from 15% to 30%: body activates mechanisms to maintain homeostasis. Clinical symptoms manifest.
C. Progressive or third stage—30 to 40% blood loss: as the compensatory mechanisms fail, requires immediate interventions. Decreased perfusion and altered cellular permeability.
D. Refractory—more than 40% volume loss: profound hypotension and hypoxemia; life-threatening.
E. If victim remains in shock, it will lead to death of cells, tissue, and organs.

  • Body initially compensates for blood loss—check signs carefully.
  • Continually evaluate client’s condition.

Assessment
A. Assess for early signs due to

  • Anxiety, thirst, postural changes in vital signs.
  • Tachycardia, tachypnea, narrow pulse pressure.
  • Increased sympathetic nervous system activity.

B. Observe for signs/symptoms of shock.

  • Rapid, shallow breathing.
  • Cold, pale skin (capillary refill > 2/second).
  • Failure to respond to simple commands.

C. Observe for oliguria.

  • Kidneys normally receive 20% of cardiac output, so if urine volume drops acutely, assume cardiac output has dropped.
  • If urine output falls below 30 mL/hr, notify physician immediately.

D. Note Kussmaul breathing—as blood pH is lowered, the respiratory rate increases in an effort to blow off excess carbon dioxide and return body to acid– base balance.
E. Assess if cool, dry, or moist skin is present.

  • Caused by peripheral vasoconstriction.
  • Blood is diverted to vital organs rather than to skin.

F. Observe sensorium changes—due to brain hypoperfusion.

  • Restlessness/anxiety.
  • Lethargy.
  • Confusion.

G. Note fatigue and muscle weakness—result of shift from aerobic to anaerobic metabolism leading to lactic acid buildup.
H. Assess for severe shock.

  • Blood pressure—systolic below 80 mm Hg and narrowing of pulse pressure to 20 mm Hg or below (body loses ability to compensate and blood pressure drops rapidly).
  • Shallow, irregular respirations.
  • Sustained tachycardia.
  • Level of unconsciousness; progresses to coma as blood supply to brain decreases.
  • Dilated, fixed pupils due to brain hypoxia.
  • Anuria as perfusion to kidneys decreases sharply.
  • Cyanotic skin, mucous membranes, and nailbeds— indicates poor prognosis.

Implementation
A. Treat the cause of shock (stop bleeding).
B. Maintain open airway—provide oxygen via mask or cannula—monitor pulse oximetry.
C. Administer fluids to treat shock state.

  • First-line treatment is crystalloids (isotonic fluids).
  • Prepare client for IV fluid, colloids–plasma expanders, blood replacement.

D. Place client in supine position with legs elevated (6–10 inches), head on pillow.

E. Insert Foley catheter for hourly urine monitoring.

  • Record intake and output (I&O).
  • Notify physician if urine output is less than 30 mL/hr.

F. Record vital signs every 15 minutes.

  • Blood pressure.
    a. Orthostatic hypotension develops before systemic hypotension.
    b. Decreased BP is usually late sign of shock.
    c. Progressive drop in BP (systolic blood pressure [SBP] < 90 mm Hg) with a thready, increasing pulse indicates hypovolemia.
  • Respirations.
    a. Rapid early in shock (compensation for tissue hypoxia).
    b. Emergency equipment for intubation/ ventilator should be available.
  • Central venous pressure (CVP).
    a. CVP reflects volume status (preload).
    b. If below 5 cm H2O, indicates hypovolemia.

G. Monitor client responses.

  • Change in skin temperature and color reflect changes in tissue oxygenation and perfusion.
    a. Cold, clammy, pale skin indicates peripheral vascular constriction.
    b. Pallor and cyanosis indicate tissue hypoxia.
  • Restlessness indicates cerebral hypoxia.
  • Assess for improvement in vital signs.

H. Maintain body temperature.
I. Avoid rough or excessive handling.
J. Do not allow client to eat or drink.

Emergency Nursing: Cardiogenic Shock

Focus topic: Emergency Nursing

Characteristics
A. Definition: Myocardial dysfunction that results in reduced cardiac output and compromised tissue perfusion.

  • Systolic dysfunction: inability to pump blood forward (myocardial infarction; MI).
  • Diastolic dysfunction: ventricles are unable to adequately fill (cardiac tamponade).

B. Causes.

  • Decrease in cardiac output—loss of myocardial contractility.
  • Most common cause is myocardial infarction with greater than 40% muscle necrosis.

C. Pathophysiology.

  • Decreased cardiac output causes sympathetic nervous system stimulation, which produces vasoconstriction and inadequate tissue perfusion, resulting in anaerobic metabolism.
    a. Result is increased lactate.
    b. Increased lactate causes metabolic acidosis.
  • Decreased cerebral perfusion.
  • Decreased renal perfusion, resulting in decreased urine production.

Assessment
A. Differentiate from hypovolemic shock.

  • Pulmonary capillary wedge pressure and CVP are increased in cardiogenic shock.
  • Pulmonary capillary wedge pressure and CVP are low in hypovolemic shock.

B. Hypotension (less than 90 mm Hg, or 300 mm Hg less than client’s normal BP) and a low cardiac index (< 2.2 L/min/m2) are classic signs of shock.
C. Measure urinary output. May be less than 30 mL/ hr due to poor renal perfusion (oliguria).
D. Assess for signs and symptoms of decreased cardiac output.

  • Pallor or cyanosis.
  • Hypoxia (decreased PO2).
  • Orthopnea.
  • Dyspnea.
  • Dependent pitting edema.
  • Distended neck veins.
  • Pulmonary congestion.
  • Cool, pale, moist skin.
  • Decreased orientation, fatigue.
  • Tachycardia; arrhythmias.

E. Assess for acidemia—decreased pH of the blood.

Implementation
A. Oxygen therapy or mechanical ventilation to increase PO2, decrease work of breathing.
B. Monitor medications.

  • Diuretics for pulmonary congestion.
  • MS Contin (morphine sulfate) for pain; vasopressors for hypotension unresponsive to fluid therapy.
  • Vasodilators: Nipride (nitroglycerin) to decrease ventricular afterload.
  • Symmetrel (dobutamine)—causes less vasoconstriction and tachycardia and may be ordered following stabilization of blood pressure.

C. Intra-aortic balloon pump (IABP) is used for internal counterpulsation.

  • Regular inflation and deflation of the balloon augments pumping action of the heart.
  • Hemodynamic monitoring is important to monitor status of client.

D. Establish fluid and electrolyte acid–base balance.

  • Replace fluid if hypovolemic.
  • Correct acidosis (improve cardiac output).
  • Maintain urinary output—greater than 30 mL/hr.

E. Control pain and restlessness by IV analgesia.
F. Treat arrhythmias—result of hypoxia, acidosis, electrolyte imbalance, underlying disease, and drug therapy.

G. Decrease cardiac workload.

  • Physical and emotional rest.
  • Psychological support.
  • Comfortable position—flat with pillow, or semi-Fowler’s position if client has difficulty breathing.

Emergency Nursing: Distributive (Vasogenic ) Shock

Focus topic: Emergency Nursing

Definition: Three types—septic, neurogenic, and anaphylactic. In all three, shock occurs as a result of vasodilation and abnormal distribution of fluids within the circulatory system.

Emergency Nursing: Septic Shock

Focus topic: Emergency Nursing

Characteristics
A. Most common type of distributive shock—caused by infection (gram-negative or gram-positive bacteria).
B. Progresses to bacteremia—bacteria enter bloodstream directly from site of infection or from toxic substances released by bacteria into the bloodstream.
C. Nonspecific inflammatory response and specific immune responses initiated with release of biochemical mediators.

  • Secondary mediators cause release of proinflammatory cytokines.
  • Cytokines cause endothelial cell damage and multiple organ dysfunction.

D. Usually occurs in two phases.

  • Phase 1: high cardiac output with vasodilation. Client is overheated and demonstrates warm, flushed skin.
  • Phase 2: low cardiac output with vasoconstriction. Blood pressure drops; skin is cool and pale.

E. Multiple-organ dysfunction syndrome (MODS)—mortality rate high—40% (sepsis is 11th highest cause of death in United States).

Assessment
A. Phase 1—may appear to be mild infection.

  • Vital signs and mental confusion may be first sign with increased heart rate or increased respiratory rate.
  • Assess for flushed, pink face warm to the touch; dry skin.
  • Observe for low blood pressure and pulse.
  • Check results of complete blood count—blood culture to determine organism.

B. Phase 2.

  • Assess for tachycardia; blood pressure decreases; PO2 is dropping.
  • Does not appear pink and warm—cool skin.
  • Observe for tachypnea.
  • Assess urine output—may drop to 30 mL per hour.
  • Assess for thirst.

Implementation
A. Goal of treatment for septic, neurogenic, and anaphylactic shock includes hemodynamic support.

  • Fluid replacement (and blood products).
  • Vasopressors and inotropes.
    a. Inotropic drugs: Intropin (dopamine)—if tissue perfusion is inadequate.
    b. Levophed (norepinephrine)—potent vasoconstrictor if dopamine does not raise mean arterial blood pressure.
    c. Narcan (naloxone)—may be ordered to treat gram-negative septic shock; attacks bacterial endotoxin that causes cellular destruction.

B. Administer broad-spectrum antibiotics as ordered—begin stat (do not wait for regular medication times).

  • Continue to check IV site frequently—if evidence of infection, restart IV in a new site.
  • Check blood urea nitrogen (BUN) level regularly.

C. Administer oxygen as ordered (mechanical ventilation)—concentration should be moderate; pulse oximeter reading useful for SaO2.
D. Take vital signs hourly. Stages can progress rapidly.
E. Observe continually for change in pattern: blood pressure down, pulse and respirations up. Notify physician immediately.
F. Check PO2 and pH—client may go into metabolic acidosis. Notify physician if pH falls below 7.35.
G. Give frequent skin care and perfusion to prevent breakdown.
H. Check I&O frequently; pay attention to amount of urine from catheter.

  • If urine output falls below 30 mL/hr, notify physician immediately.
  • Prevent fluid overload by calculating previous hourly urine output plus 30 mL/hr.

I. Provide appropriate psychological support.

  • Client is frightened, so remain in the room.
  • Explain all procedures and attempt to alleviate anxiety.

J. Observe for complications or reversal in improvement of shock state.

  • Respiratory: dyspnea, cyanosis, intercostal retractions (shock lung).
  • Cardiac: heart failure—may require digitalis.
  • Renal: oliguria—may require Mannitol.

Emergency Nursing: Neurogenic (Spinal) Shock

Focus topic: Emergency Nursing

Definition: Massive vasodilation and pooling of blood due to failure of peripheral vessels; imbalance of parasympathetic/ sympathetic vascular tone (also see Spinal Cord Injury, page 190).

Characteristics
A. Interference with sympathetic nervous system (head injury).
B. Injury to spinal cord or as a result of spinal anesthesia.
C. Severe pain, drugs, or hypoglycemia causing vasomotor center depression.

Assessment
A. Assess for hypoglycemia, bradycardia, or hypothermia.
B. Assess vital signs; hypotension.
C. Loss of reflex activity in spinal cord below injury level (areflexia).
D. Paralytic ileus.

Implementation
A. Monitor CAB (circulation, airway, and breathing).
B. Fluid resuscitation to increase blood pressure.
C. Monitor vasoconstrictors to increase blood pressure.
D. Monitor atropine-like drugs to block vagal effects causing bradycardia.
E. If hypothermia present, requires warming measures.

Emergency Nursing: Anaphylactic Shock

Focus topic: Emergency Nursing

Definition: A severe allergic reaction that is rapid in onset and may be fatal. It is often a reaction to an antigen to which the body has become hypersensitive.

Characteristics
A. A whole-body allergic reaction caused by hypersensitivity to allergen (allergic reaction to medication, bee sting, nuts, etc.).
B. Antigen–antibody reaction.
C. Increased cell membrane permeability—histamine is released, causing marked vasodilatation.
D. Bronchiolar constriction and hypoxia.
E. Pooling of blood, causing decreased venous return.
F. Decreased cardiac output and hypoxia.

Assessment
A. Assess for dyspnea, respiratory difficulty, cyanosis, wheezing (can be life-threatening).
B. Observe for vertigo, decreased blood pressure, increased pulse.
C. Evaluate local edema, skin rash, flushing, urticaria (occasional), and restlessness.
D. Evaluate if apprehension is present.

Implementation
A. Goal is to maintain a patent airway and insure breathing.
B. Identify causative agent.
C. Position client for optimal cerebral perfusion (flat or 30-degree elevation if dyspneic).
D. Administer epinephrine subcutaneously.

  • Dilates bronchioles and constricts arterioles.
  • Side effects: tachycardia, central nervous system (CNS) stimulation.
  • Rapid acting.

E. Administer oxygen.
F. Administer antihistamine

  • H1 blockers: Benadryl (diphenhydramine).
    a. Relieves itching, wheals, congestion of nasal mucosa.
    b. Side effect: Dries mucous membranes.
  • H2 blockers: Tagamet (cimetidine), Zantac (ranitidine), Pepcid (famotidine).

G. Maintain IV of normal saline (NS) or lactated Ringer’s to support perfusion.
H. Administer corticosteroids—reduce formation of cellular proteins and decrease edema. They have no immediate effect but may be given to prevent biphasic reaction.
I. Administer inhaled beta-2 adrenergic agonists such as Proventil (albuterol) to promote bronchodilation.
J. Teach client and family about the need for Medic-Alert identification and use of the EpiPen (epinephrine).

Emergency Nursing: Snake Bite

Focus topic: Emergency Nursing

Assessment
A. Assess extent of envenomation.

  • Rattlesnakes, copperheads, and cottonmouths (pit vipers) are responsible for 98% of venomous bites.
    a. Pit viper venom is hemolytic.
    b. Coral snake venom is neurotoxic.
  • Reactions to poisonous snakes occur within 15 minutes.
  • Signs.
    a. One or two distinct puncture wounds, fang marks.
    b. Burning pain.
    c. Edema and erythema.
    d. Serosanguineous fluid oozing from wound.
    e. Numbness around bite within 15 minutes.

B. Assess systemic signs.

  • Diaphoresis, chills.
  • Anxiety.
  • Tachycardia, hypotension.
  • Temperature elevation.
  • Tingling of tongue, rubber or metal taste.
  • Visual disturbance; seizure.
  • Nausea/vomiting.
  • Dizziness.
  • Muscle fasciculations.
  • GI bleeding.
  • Respiratory problems.

Implementation
A. Emergency treatment: seek medical help immediately.

  • Immobilize area with support or sling and position below heart.
  • Remove constrictive clothing or jewelry.
  • Do not apply a tourniquet or ice.
  • Do not allow client to physically exert self, as this hastens spread of venom. Keep client still.
  • Do not incise area or apply suction.

B. In-hospital treatment.

  • Skin test for sensitivity to horse serum.
  • Administer prescribed antivenin intravenously.
    a. Dilute antivenin dose in saline (250–500 mL).
    b. Dose based on severity of envenomation.
    c. Have EpiPen (epinephrine) available in case of allergic reaction.
  • Monitor vital signs.
  • Monitor for decreased swelling.
  • Monitor blood coagulation studies.
  • Type and cross-match blood.
  • Administer analgesics for pain.
    a. Aspirin (acetylsalicylic acid; ASA) for mild pain.
    b. Codeine or Demerol (meperidine) for severe pain.
  • Administer antibiotics.
    a. Initial dose: Amoxil (ampicillin), Erythrocin (erythromycin), or Tetracyn (tetracycline) 500 mg.
    b. Maintain 250 mg every 4 hours for 24 hours.

C. Monitor for complications.

  • Respiratory arrest due to neurotoxin.
  • Acute renal failure due to hemolysis.
  • Disseminated intravascular coagulation (DIC).
  • Compartment syndrome; gangrene.
  • Infection.
  • Delayed serum sickness.

Emergency Nursing: Bee Sting

Focus topic: Emergency Nursing

Assessment
A. Tightness in chest, difficulty swallowing or breathing.
B. Generalized swelling and itching.
C. Erythema and hives.

D. Feeling of heat throughout body.
E. Weakness, vertigo.
F. Nausea, vomiting, abdominal cramps.

Implementation
A. Remove stinger by scraping motion with dull object like a credit card in the opposite direction of the angle of penetration. Do not grasp or pull stingers, this can squeeze the attached sac and inject more venom.
B. Cleanse sting area and apply ice to relieve pain and edema.
C. Observe for signs of laryngospasm or bronchospasm. Be prepared to assist with a tracheostomy.
D. Keep client warm and positioned supine with head and feet slightly elevated.
E. For client going into full-blown anaphylactic shock, implement following orders.

  • Immediately administer EpiPen (epinephrine) 1:1000 solution sub q.
    a. Adult: 0.25–0.3 mL at sting site and same amount in unaffected arm.
    b. Child: 0.01 mL/kg (maximum 0.25 mL at each site).
  • Repeat injections one to three times at 20-minute intervals until blood pressure and pulse rise toward normal.
    a. Adult: 0.3–0.4 mL.
    b. Child: less than 20 kg, 0.10–0.15 mL; over 20 kg, 0.15–0.3 mL.
  • Administer pressor agents if blood pressure does not stabilize following two to three sub q injections of epinephrine.
    a. Aramine (metaraminol) and Levophed norepinephrine are drugs of choice.
    b. Administer IV drip at 30–40 drops/min.
  • Begin IV solution of D5W with 250 mg Phyllocontin (aminophylline) and 30–40 mg Solu-Cortef (hydrocortisone) to support circulation and prevent shock.
  • Administer rapid-acting antihistamine: Benadryl 50 mg intramuscular (IM).

Emergency Nursing: Cardiopulmonary Resuscitation

Focus topic: Emergency Nursing

Indications
A. Respiratory arrest with pulse present—establish airway, breathing.
B. Cardiac arrest with ineffective breathing.
C. No movement or response.

Assessment and Actions
A. BLS Adult Healthcare Provider Algorithm.

B. Summary of BLS Maneuvers for Adults, Children, and Infants (see Table 10-1).
C. Termination of CPR.

  • Successful resuscitation.
    a. Spontaneous return of adequate life support.
    b. Assisted life support.
  • Transfer to emergency vehicle (other trained rescuers assume care).
  • Pronounced dead by physician.
  • Exhaustion of rescuer(s).

Emergency Nursing

Emergency Nursing: Using an AED

Focus topic: Emergency Nursing

A. Initial steps.

  • Place AED near victim’s left ear.
  • Open AED, turn on power switch, and lift up monitor screen. Follow prompts.
  • Open defibrillator pads and connect to cables and to victim’s chest.
  • Stop CPR (if second rescuer performing).
  • Shout, “Stand clear.”

B. Check rhythm.

  • Shockable rhythm—give one shock, resume CPR immediately for five cycles.
  • Not shockable rhythm—resume CPR immediately for five cycles.
  • Check rhythm every five cycles and continue until advanced life support (ALS) provider takes over or victim moves.

Emergency Nursing

Emergency Nursing

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Emergency Nursing: Heimlich Maneuver

Focus topic: Emergency Nursing

A. Airway obstruction management.

  • Victim standing or sitting.
    a. Make fist with one hand.
    b. Place thumb side of fist against victim’s abdomen, between umbilicus and xiphoid process.
    c. Grasp fist with other hand and press fist into victim’s abdomen with quick upward thrust.
    d. Repeat thrusts until object expelled from victim’s airway or victim collapses.
  • Victim lying down.
    a. Place victim supine.
    b. Kneel astride victim’s thighs and place heel of one hand against victim’s abdomen (between xiphoid process and umbilicus).
    c. Place other hand on top of first.
    d. Press into abdomen with quick upward thrust.

SUMMARY OF BLS MANEUVERS FOR ADULTS, CHILDREN, AND INFANTS

Focus topic: Emergency Nursing

Emergency Nursing

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