Emergency & Critical Care Nursing PDF

Nursing 2 -- Lecture 10 Triage in Veterinary Medicine Purposes of Triage 1. Rapid assessment of patients in need of immediate care (closest to death goes first) 2. Prioritization of care for incoming patients Telephone Triage 1. Answer the phone - You never know what is on the other...

Nursing 2 -- Lecture 10 Triage in Veterinary Medicine Purposes of Triage 1. Rapid assessment of patients in need of immediate care (closest to death goes first) 2. Prioritization of care for incoming patients Telephone Triage 1. Answer the phone - You never know what is on the other end - If you don't answer & triage, people just show up - May be a real emergency or may just be an emergency to the client 2. Obtain client name & phone number - In case phone call is disconnected - Must be a number patient can be reached at - Happens often -- dying cell phone -- owner panics 3. Determine How Urgent? - Done by collecting basic history - What, when, duration, current status, where & ETA or direct elsewhere, concerns or related illnesses - Does clinic carry equipment to manage emergency 4. Give Advice - Ideally where to go for professional care - Sometimes appropriate first aid - Apply pressure to bleeding site - How to transport patient - Be careful around patient (can bite if in pain, unpredictable due to seizure) - Need to vomit? Hydrogen peroxide administration? 5. Do Not Waste Time - A true emergency -- life and death can differ by a matter of minutes (hemorrhaging patient, bloat) - If you are not sure get another tech or vet immediately - Do not worry about non pertinent information (vaccine status, deworming etc) Patient Arrival & Assessment Notice or a Walk-In As soon as client walks into waiting room, RVT determines patient "acuity" level - Ask what happened, observe & greet - Determine: ok to wait or not? If not, move to treatment area - Life threatening problems dealt with first Cardiovascular, resp, neurologic - Evaluation/resuscitation begin immediately Assessing Patient in Triage - Multitask - Obtain brief history, visual & physical exams, completed within 1-2 min - Goal is sorting 1. Need immediate care/stabilization 2. Those that need to go to treatment area for other reasons (vomiting, diarrhea, contagious, injury) 3. Those that can wait with owner until appointment time (ear infection, tick removal, broken nail that is not bleeding) **Primary Survey** - Rapid evaluation for critical problems (1-2mins) - Take a brief Hx from owner (pertinent info) - Asses "ABC's" Airway Breathing Consciousness - Variations in "ABC's (alertness, breathing, cardiovascular) - Be prepared with your tools (stethoscope, watch, thermometer, muzzle, towels etc) Airway - Look at breathing & any signs or resp distress - Increased effort - Stance, posture - Abdominal wall movement - Nasal flare, open mouth - Hand in front of nostrils to determine air flow - Labored, tachypnea, orthopnea - Fast, shallow, abdominal effort - Look in mouth Listen - Both lungs (before heart) - Don't forget tracheal - Abnormal sounds -- loud snorting, roaring, wheezing, decreased/absent sounds, crackles Feel - Palpate trachea - Palpate chest wall for fractures, wounds, subcutaneous emphysema - Multitask: do this while auscultating Bleeding Active bleeding, especially arterial - Direct pressure - +/- fast bandage = gauze, vet wrap - Tourniquet (rubber, rope, shirt, fabric) Consult DVM Can only be applied for 20 mins For extended amount of time only if amputation option Only around legs/tail never head or body =/- hemostat clamp bleeding vessel - MM colour, CRT- - auscultate heart Estimate HR (tachy, brady, normal) Asses rhythm , any obvious arrythmia - palpate pulse (quality, strength, bounding, thready) - rectal temp - feel paws/extremities for warmth - hydration - rapid palpation of abdomen (fluid wave, tense/painful, wound, distension) - if bloat is suspected, can auscultate and "ping" for tympany over abdomen Consciousness Mentation - neurological concerns/signs - may suggest cerebral injuries, toxin, spinal cord, pathogen, fever - normal (alert and interactive) - dull/depressed (interactive but not bright or eager) - obtunded (reacts to stimuli but very slowly or at a lower level) - Stuporous (disconnected fro environment, only reacts to noxious stimuli like loud noise or pain - Comatose (disconnected from environment, does not react to stimuli - Simply put -- alert, verbally responsive, responsive to pain, unresponsive - Pain perception Skin pinches, toe pinches - Pupils Mydriatic pupils (big) -- fixed & dilated, bad if not responsive otherwise PLR time Compare both sizes, same or different? Gait/Posture - Guarded (painful) - Laterally recumbent - Limping/non weight bearing - Sawhorse stance - Rigid (fore limbs vs hind limb) - Help localize injuries (TBI, spinal, fracture/trauma) Primary Survey completed within 1-2 mins. Recall: - Multitask Look. Listen & feel at the same time - Trage Catastrophic abnormalities dealt with now ABC's: Airway, bleeding/trauma, consciousness **Secondary Survey** After immediate problems are addressed (pressure bandages, catheter/IV etc) Complete history taken, full PE completed, Diagnostics plans Vital Signs - Measure & record - HR & auscultate - Pulse rate & quality - CRT, MM color & moisture - RR & Auscultation - Blood Pressure - Body temp & how extremities feel Also - ECG - QATS or QUATS -- quick assessment test PCV, TP, BUN, BG - Baseline bloodwork CBC, chemistry/electrolytes, blood gases **Crash Cart** Always be prepared - Supplies needed for "unstable" patients - Usually arranged according to "task" - Airway supplies, resuscitation supplies, emergency drugs etc **Shock** AKA circulatory shock is a medical emergency in which the organs & tissues with inadequate blod flow (poor perfusion). This deprives the organs and tissues of oxygen, & allows the buildup of waste products Shock can result in serious cell/tissue/organ damage or death It is a condition (not a disease) - Decreased 02 delivery leads to: Lack of energy production (ATP) within the cell (cellular respiration) Results in cell death -- leads to organ dysfunction & failure Goals & Treatment - Restore tissue perfusion & 02 delivery to normal - Get them out of shock & prevent death Circulatory System has 3 components Pump = heart Pipes = blood vessels Fluid = blood/plasma/serum - Shock can occur with failure of any component - Shock can be categorized based on which component failed **Types of Shock** Cardiogenic Shock -- Heart - Cardiac diseases like hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), microvascular dysplasia, arrythmias Hypovolemic Shock -- Blood - Causes of decreased intravascular volume Distributive -- Vessels - Decreased vessel tone - Sepsis, anaphylaxis, neurogenic states Obstructive -- Vessels - Obstructive to blood flow - Heartworm disease, clot, bloat or gastric dilation volvulus **Pathophysiology 3 Steps in Process** 1. An event that leads to decreased cardiac output & hypotension 2. Body tries to compensate for incident -- SNS kicks in -- fight/flight/freeze 3. Response to hormones -- arteriolar constriction caused by epinephrine & norepinephrine secretion. Blood redirected to heart & brain -- away from skin, muscle, kidneys, GI **Stage One of Shock** Compensated - Signs -- Activation of SNS Increased HR, Peripheral vasoconstriction Prognosis likely fair to guarded Tachycardia & tachypnea Decreased pulse quality Prolonged CRT Pale MM Cool extremities Cats -- do not always display the classic signs of shock like dogs do - Bradycardia - Hypothermia - Hypotension - Even in early stages of shock Patient progresses to stage 2 if treatment or the body's effort at compensation are not sufficient Decompensation - Arterioles are starting to become exhausted - Tachycardia - Weaker pulse - MM color (muddy/gray/cyanotic) - Variable CRT - Hypothermia - Weakness, decreased LOC - Prognosis is guarded to poor Irreversible Shock - Patient us unconscious or unresponsive - Prolonged hypoxemia results in systemic vasodilation, BP plummets & CV collapse occurs - MM color: muddy - Cold extremities, hypothermia common - Therapy is not effective, rapid decline - Prognosis -- fatal Shock = widespread tissue hypoxia and damage (longer = worse even if you manage to resuscitate them) Extensive inflammation activates mediators all through body (disruptive shock) but no infection present Extensive inflammation activates mediators all through body (disruptive shock) but no infection present - Called systemic inflammatory response syndrome - Results in widespread vasodilation which leads to hypotension, tachycardia, tachypnea & fever If advances: patients develop DIC & MODS (multiple organ dysfunction syndrome) Prognosis: is poor **Reperfusion Injury** - Once shock has been treated and steps taken to improve blood flow, treatment shifts to minimize the effects of shock on the body - Lack of oxygen during shock forces cells to use anaerobic respiration resulting in increased levels of lactate and other byproducts that damage tissues & hemostasis - So when blood flow is restored during treatment of shock, lactate and free radicals are released into circulation - Wbc's are drawn to damaged tissue where they are activated and release additional inflammatory mediators - Risk for SIRS always follows in patients who have been in shock - Bottom line is if you bring them back from the intital shock, they are still at risk of decompensating -- monitor closely **Nursing a Shocky Patient** - Venous access -- aggressive fluid therapy -- catheter choice matters, IO route an alternative. Try to limit resistance by limiting tubing. - Oxygen supplementation - Drugs - Treat underlying diseases - Goal is to restore 02 delivery for adequate tissue perfusion