Oncologic Nursing Procedures for Multi-Organ Failure PDF

SPECIAL PROCEDURES FOR MULTI ORGAN FAILURE ACUTE BIOLOGIC CRISIS/ MULTI ORGAN FAILURE SURGICAL PROCEDURES 1. CORONARY BYPASS 2. ANGIOPLASTY 3. SKIN GRAFTING  CORONARY BYPASS  Coronary artery bypass surgery, also coronary artery bypass graft (CABG, prono...

SPECIAL PROCEDURES FOR MULTI ORGAN FAILURE ACUTE BIOLOGIC CRISIS/ MULTI ORGAN FAILURE SURGICAL PROCEDURES 1. CORONARY BYPASS 2. ANGIOPLASTY 3. SKIN GRAFTING  CORONARY BYPASS  Coronary artery bypass surgery, also coronary artery bypass graft (CABG, pronounced "cabbage") surgery, and heart bypass or bypass surgery. -is indicated for patients with coronary artery disease to relieve symptoms, improve quality of life, and/or prolong life - is a surgical procedure performed to relieve angina and reduce the risk of death from artery disease. *Arteries or veins from elsewhere in the patient's body are grafted to the coronary arteries to pass artherosclerotic area, narrowing and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle).  This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass; techniques are available to perform CABG on a beating heart, so-called "off- pump" surgery. Sources of grafts can be the : 1.internal mammary artery 2.radial artery 3. gastroepiploic artery 4. saphenous vein.  The internal mammary and the saphenous vein continue to be most commonly used for grafts. Postoperative Pulmonary Management 1. Pulmonary dysfunction hypoxemia & pulmonary complications - adequate oxygenation and ventilation while the patient is intubated (Early extubation isalso a desired outcome as long as the patient is hemodynamically and neurologically stable) increase in postoperative complications when patients are intubated longer than 24 hours. (promote oxygenation and ventilation involves prevention and treatment of atelectasis and pulmonary infection as well as maintenance of effective gas exchange and breathing patterns) - Atelectasis, inhibits diffusion of oxygen and carbon dioxide across the alveolar capillary membrane and impairs effective gas exchange. Prolonged pump time causes fluid shifts, potentially increasing the amount of fluid in the pulmonary tissue, thus increasing the possibility of pulmonary complications - Pain caused from the sternotomy can impair breathing patterns. Some patients shiver after heart surgery and this response may lead to an increase in the carbon dioxide level or lead to lactic acidosis. - Shivering may increase the body's oxygen consumption, therefore, oxygen levels should be monitored and adjusted accordingly. Shivering may be the result of the body compensating for the surgically induced hypothermia or a reaction to anesthetic agents. *Shivering is usually managed by administration of sedation and neuromuscular blocking agents while the patient is being mechanically ventilated. 2. Intraoperative myocardial ischemia is a potential cause of low cardiac output (CO) during the immediate postoperative period - The nurse must continually assess the patient for cardiac dysfunction and hemodynamic instability. The receiving nurse must intensively monitor the interrelationship between heart rhythm and rate, preload, afterload, contractility, and myocardial compliance to achieve this outcome. *Preload is determined by the volume of blood returning to the right atrium as well as by myocardial compliance. Preload is a measurement of end diastolic pressure. *Afterload is the force the left ventricle must overcome to eject blood during systole. It is determined, in part, by myocardial contractility and systemic vascular resistance. Myocardial contractility refers to the force generated by the heart during systole. Blood pressure must be maintained within ordered parameters to provide tissue perfusion and prevent disruption of the surgical anastomoses. 3. Dysrhythmias are common after CABG surgery - Constant assessment of the patient, as well as continuously monitoring the cardiac rate and rhythm, is imperative. Ventricular dysrhythmias are more common in the early postoperative period and supraventricular dysrhythmias are more likely 24 hours to 5 days postoperatively. Dysrhythmias may result in an increase in catecholamine levels secondary to pain, anxiety, and inadequate sedation. Management depends on the type of dysrhythmia, nurse must treat the patient and not only the monitor. Effectiveness of BP and CO should be considered when evaluating dysrhythmias. *Often, cardiac surgeons place epicardial wires on the atrium and/or the ventricle during the operation-temporary pacing can be instituted to override a slow intrinsic rhythm, atropine may be given to increase the heart rate in the absence of epicardial pacing wires. *Tachydysrhythmias are usually controlled pharmacologically depending on hospitals protocols and physicians preference. The critical care nurse should utilize standing orders in the institution as well as current advanced cardiac life support Catecholamines (dopamine and norepinephrine)- neurotransmitters that mediate a variety of the central nervous system functions, such as motor control, cognition, emotion, memory processing, and endocrine modulation. 4. Bleeding - assessing the patient's potential for bleeding, patients who were on anticoagulants and antiplatelet agents - other potential sites for bleeding include: 1. internal mammary site 4. chest tube sites 2. the chest wall 5. induced hypothermia 3. the use of the CPB machine 6.the administration of heparin for anticoagulation can all contribute to postoperative bleeding. *The nurse should be aware that heparin can be stored in adipose tissue and some patients may have an increase in bleeding 4 hours postoperatively depending on the body's adipose composition. Some surgeons utilize an intravenous infusion of aprotinin intraoperatively to minimize the risk of postoperative bleeding. This drug is a protease inhibitor that inhibits fibrinolysis. Aprotinin may also have some anti-inflammatory effects and therefore be beneficial to the patient after CABG. *The nurse should monitor the patient for signs of : 1. bleeding from the chest tubes and the surgical sites 2.signs of hypovolemia related to blood loss 3. Monitor the hemoglobin and hematocrit count Bleeding persists: protamine sulfate (to reverse the effects of heparin) or antifibrinolytic agents such as aminocaproic acid or desmopressin (DDAVP) may be ordered. 5. Increased risk for neurologic complications - neurologic assessment is done frequently- pupils be observed Stroke can b.e caused by hypoperfusion or an embolic event  6. Potential for renal dysfunction - Renal insufficiency may be related to advanced age, hypertension, diabetes, decreased function of the left ventricle, and length of time on the CPB. * One indicator of effective CO is adequate renal perfusion as evidenced by urinary output of at least 0.5 mL/kg/h. *The nurse must monitor the urinary output at least hourly during the early postoperative period. The urine should be assessed for color and characteristics as well as amount. *Diuresis is likely in the postoperative period when renal function is adequate, as the fluids mobilize from the interstitial to the intravascular space. Intravenous potassium replacement should be administered to keep the serum potassium levels within normal limits. The patient should be strictly monitored for cardiac dysrhythmias if the serum potassium level is abnormal. 7. Gastrointestinal complications Complications include: 1. peptic ulcer disease 4. acute cholecystitis 2.perforated ulcer 5. bowel ischemia 3.Pancreatitis 6. diverticulitis 7.liver dysfunction *The nurse should administer antiemetic agents as ordered if the patient is nauseated. The comfort of the patient as well as the sterility of the sternal dressing must be maintained. Some surgeons order a histamine blocker to minimize acid secretion until normal dietary patterns are resumed. When the nasogastric tube is removed, the patient will be started on a clear liquid diet and this can be advanced as tolerated by the patient. 8. Pain *Dependent upon surgical approach, the patient may have a median sternotomy incision, leg incision(s), and/or a radial incision. Manipulation of the chest cavity, use of retractors during surgery, and electrocautery may all contribute to postoperative pain *Poorly controlled pain can stimulate the sympathetic nervous system and lead to cardiovascular consequences. The heart rate and BP can increase and the blood vessels can constrict, causing an increase in the cardiac workload and myocardial oxygen demand.Effective pain control is essential for patient comfort, hemodynamic stability, and prevention of pulmonary complications.  Angioplasty  is the technique of mechanically widening narrowed or obstructed arteries, the latter typically being a result of atherosclerosis. An empty and collapsed balloon on a guide wire, known as a balloon catheter, is passed into the narrowed locations and then inflated to a fixed size using water pressures some 75 to 500 times normal blood pressure(6 to 20 atmospheres)  The balloon forces expansion of the inner white blood cell/clot plaque deposits and the surrounding muscular wall, opening up the blood vessel for improved flow, and the balloon is then deflated and withdrawn. A stent may or may not be inserted at the time of ballooning to ensure the vessel remains open.  Nursing Management: PTCA or Percutaneous Transluminal Coronary Angi oplasty on the other hand involves introducing a balloon catheter through the groin, sometimes of the arm. It is placed within the blood vessel that is why it is medically called transluminal. Before the Procedure:  Inform the patient that a catheter will pass through the artery and a vein in the groin area.  Reassure the patient that the procedure lasts from one to four hours and he or she will lie flat on the operating table all the time.  Advice deep breathing episodes during the procedure to provide ease with the process. After the Procedure:  Inform the patient that he or she will spend ample time in the cardiac ICU or a certain facility wherein closer monitoring will be done until he or she is stable.  Monitor the heparin effects and other intravenous medications.  Asses for the peripheral pulses from time to time, there is a tendency that it will be impeded due to prolonged supine position. Discharge Instructions:  When the patient goes home, emphasize that it he or she experienced complications such as bleeding or lack of sensation on the lower extremity, inform to call the attending physician immediately.  Instruct that if chest pains happen there would be a tendency for the reinsertion of the catheter.  Skin Grafting  Skin grafting is a type of graft surgery involving transplantation of skin. The transplanted tissue is called a skin graft.  Skin grafting is often used to treat: 1. Extensive wounds or trauma 2. Burns 3. Areas of extensive skin loss due to infection such as necrotizing fasciitis or purpura fulminans  Specific surgeries that may require skin grafts for healing to occur - most commonly removal of skin cancers  Skin grafts are often employed after serious injuries when some of the body's skin is damaged. Surgical removal (excision or debribement) of the damaged skin is followed by skin grafting.  The grafting serves two purposes: 1. reduce the course of treatment needed (and time in the hospital), and improve the function 2. appearance of the area of the body which receives the skin graft.  There are two types of skin grafts: 1. The more common type is where a thin layer is removed from a healthy part of the body (the donor section) like peeling a potato, or thin layer or partial thickness skin graft, which involves pitching and cutting skin away from the donor section. 2. A full thickness skin graft is more risky, in terms of the body accepting the skin, yet it leaves only a scar line on the donor section, similar to a Cesarean section scar. For full thickness skin grafts, the donor section will often heal much more quickly than the injury and is less painful than a partial thickness skin graft.  Graft taxonomy  Autologous: The donor skin is taken from a different site on the same individual's body (also known as an autograft).  Isogeneic: The donor and recipient individuals are genetically identical (e.g., monozygotic twins, animals of a single inbred strain;isograft or syngraft).  Allogeneic: The donor and recipient are of the same species (human→human, dog→dog; allograft).  Xenogeneic: The donor and recipient are of different species (e.g., bovine cartilage; xenograft or heterograft).  Prosthetic: Lost tissue is replaced with synthetic materials such as metal, plastic, or ceramic (prosthetic implants).  SPECIAL PROCEDURES Advanced Life Support (ALS) is a set of life-saving protocols and skills that extend Basic Life Support to further support the circulation and provide an open airway and adequate ventilation (breathing). - refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.  ALS assumes that BLS (bag-mask administration of oxygen and chest compressions) are administered.  Monitor of the electrical activity of the heart on a cardiac monitor. Depending on the type of cardiac arrhythmia, defibrillation is applied, and medication is administered. Oxygen is administered and endotracheal intubation may be attempted to secure the airway.  Medication that may be administered may include adrenaline (epinephrine), amiodarone, atropi ne, bicarbonate, calcium, potassium and magnesium. Saline or colloids may be administered to increase the circulating volume.  While CPR is given (either manually, or through automated equipment such as Auto Pulse.  Note these reversible causes are usually taught and remembered as 4Hs and 4Ts 1. hypoglycaemia 2. acidosis with hyper/hypokalaemia 3. 'metabolic causes' and omitting trauma from the T's as this is redundant with hypovolaemia—this simplification aids recall during resuscitation.  H’S AND T’S IN ADVANCED CARDIAC LIFE SUPPORT Hs  Hypoxia: low oxygen levels in the blood  Hypovolemia: low amount of circulating blood, either absolutely due to blood loss or relatively due to vasodilation  Hyperkalemia or hypokalemia: disturbances in the level of potassium in the blood, and related disturbances of calcium ormagnesium levels.  Hypothermia/Hyperthermia: body temperature not maintained  Hydrogen ions (Acidosis)  Hypoglycemia: Low blood glucose levels Ts  Tension pneumothorax: increased pressure in the thoracic cavity, leading to decreased venous return to the heart  Tamponade: fluid or blood in the pericardium, compressing the heart  Toxic and/or therapeutic: chemicals, whether medication or poisoning  Thromboembolism and related mechanical obstruction (blockage of the blood vessels to the lungs or the heart by a blood clot or other material)  Ventilatory Support  Mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. This may involve a machine called a ventilator. There are two main divisions of mechanical ventilation: 1. invasive ventilation 2. non-invasive ventilation. There are two main modes of mechanical ventilaton within the two divisions: 1. positive pressure ventilation, where air (or another gas mix) is pushed into the trachea, 2. negative pressure ventilation, where air is essentially sucked into the lungs. Emergency care can be defined as the episodic and crisis ­oriented care provided to patients with serious or poten­tially life- threatening injuries or illnesses. Emergency Assessment A systematic approach to the assessment of an emergency patient is essential. Often, the most dramatic injury is not the most serious. The primary and secondary survey pro­vide the emergency nurse with a methodical approach to help identify and prioritize patient needs. Primary Assessment  (primary survey) - initial rapid assessment of the patient is meant to identify life-threatening problems (airway, breathing, & circulation). The first step in the primary assessment is to determine if the patient is conscious. If the patient is conscious, the primary assessment can be performed at a glance. a. A patient who is alert & talking indicates that there is breathing & circulation. b. A conscious patient also indicates that circulation is adequate and enough blood is being circulated to the brain. c. If, however, the patient is not fully conscious, the primary assessment should proceed step by step.  Airway: open airway?  Breathing: breathing?  Circulation: immediate jeopardy of circulation?  D­isability disability/discharges  E xpose expose  Disability & Expose  Disability - Assess level of consciousness and pupils a more complete neurologic survey will be completed in the secondary survey (i) A-Is the patient alert? (ii) V-Does the patient respond to voice? (iii) P-Does the patient respond to painful stimulus? (iv) U-The patient is unresponsive even to painful stimulus. Expose - Undress the patient to look for clues to injury or illness, such as wounds or skin lesions. Secondary Assessment (secondary survey)  a systematic, brief (2 to 3 minutes) examination of the patient from head to toe.  Purpose - to detect and prioritize additional injuries or to detect signs of underlying medical conditions.  History 1. If possible, a brief history of the chief complaint, acci­dent, or illness is taken from the patient or an accom­panying person-relative, prehospital provider.  What is the mechanism of injury-the circumstances, forces, location, and time of injury.?  b. When did the symptoms appear?  c. Was the patient unconscious after the accident?  d. How did the patient reach the hospital? ­  e. What was the health status of the patient before the accident or illness?  f. Is there a history of illness?  g. Is the patient currently taking any medications?  h. Does the patient have any allergies?  i. Is the patient under a health care provider's care (name of provider)?  j. Was treatment attempted before arrival at the hospital-home remedies, over-the-counter medica­tion, or prehospital emergency medical services care?  HOSPITAL TRIAGE (E.R. DEPT)  I. Emergent (Red) Conditions requiring immediate medical interventions. Any delay in treatment is potentially life, limb or vision threat­- ening. Includes conditions such as: 1. Airway compromise 2. Cardiac arrest 3. Severe shock 4. Cervical spine injury 5. Multisystem trauma 6. Altered level of consciousness 7. Eclampsia  Urgent (Yellow)  Patients who present as stable but whose condition re­quires medical intervention within a few hours. (1-2 hours)There is no immediate threat to life or limb or vision for these patients. 2. Conditions include: a. Fever c. minor burns b. Minor musculoskeletal injuries d. dizziness & lacerations Nonemergent (Green)  Patients who present with chronic or minor injuries.No danger to life, limb or vision by having these pa­tients wait to be seen. Time is not a critical factor & These patients are in no obvious distress. Conditions include: a. Chronic low back pain b. Routine medication refills c. Dental problems d. Missed menses Dead (Black)  CPR Cardiopulmonary resuscitation (CPR) - is a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate, definitive medical treatment can restore normal heart and ventilatory action. - Manage­ment of foreign body airway obstruction or cricothyroi­dotomy may be necessary to open the airway before CPR can be performed. CPR MANEUVERS 1. HEAD TILT CHIN LIFT (HTCL) - to maneuver to open the airway 2. JAW THRUST - maneuver to open the airway is the preferred method for use in clients with head or cervical neck injury. A - AIRWAY - Place victim flat on his/her back on a hard surface. - Shake victim at the shoulders and shout "are you okay?" If no response, call emergency medical system -then, Head-tilt/chin-lift - open victims' airway by tilting their head back with one hand while lifting up their chin with your other hand.  B - BREATHING  Position your cheek close to victims' nose and mouth, look toward victims' chest, and  Look, listen, and feel for breathing (5-10 seconds)  If not breathing, pinch victim's nose closed and give 2 full breaths into victim's mouth (use microshield). If breaths won't go in, reposition head and try again to give breaths. If still blocked, perform abdominal thrusts (Heimlich maneuver) C - CIRCULATION  Check for carotid pulse by feeling for 5-10 seconds at side of victims' neck. If there is a pulse but victim is not breathing, give Rescue breathing at rate of 1 breath every 5 seconds Or 12 breaths per minute If there is no pulse, begin chest Compressions as follows: Place heel of one hand on lower part of victim's sternum. With your other hand directly on top of first hand, Depress sternum 1.5 to 2 inches. Perform 15 compressions to every 2 breaths. (rate: 80-100 per minute) check for return of pulse every minute. A FEW CHANGES TO THE PROCEDURES 1. Cricoid pressure. To be used only under the following circumstances. The person is unconcious, when rescue breathes are administered, and when drowning is suspected. Using your thumb and index finger, first locate "Adam's apple". Move your finger and thumb slightly downwards until you feel the next tracheal cartildge (cricoid ring). Apply firm but gentle downward pressure on the cricoid ring continuosly during chest compressions and rescue breathing. One rescuer performs CPR/EAR while the second rescuer applys the cricoid pressure. You only use cricoid pressure when two or more rescuers are present.  2. Pulse checks. The checking of the pulse at the carotid point in children and adults, and the brachial point in infants has been removed. You will now observe the person for 10 seconds looking for signs of circulation, such as coughing, moving and normal breathing. This guideline change should reduce the missed opportunities to provide chest compressions and early defibrillation for cardiac arrest. When in doubt about circulation, start chest compressions.  3. Chest compressions. Chest compressions in adults for both 1 man and 2 man CPR will now be 2 breathes and 15 compressions. Children and infants stays 1 breath and 5 compressions. The reason behind this is that not enough pressure is built up in 5 compressions to get enough oxygenated blood to the brain. When doing compressions, it is done to a speed of 100 per minute. You will no longer be checked by a stop watch, it will now be on competency and effectiveness.  4. Choking. If a person (child or adult) is choking, you ask two questions. Are you choking? Person can nod head. Can you speak? Person can shake head. You immediately go behind the person with one foot placed between persons feet, turn your body to the side with your other foot bracing yourself. The person will then be leaning against your side, giving you a more solid area to thrust against, as well as preventing you from falling over when doing the upward thrust by placing your fist just above navel. Infant choking stays the same as in the SPA manual.  Recovery position: Please remember for the family and bystanders sake to put the deceased into the recovery position, as it looks more humane that the person lying flat on his back and not breathing. Remember the victims life, whether family, friend or foreigner, may depend on your ability to perform immediate and adequate resuscitation at any time. - Alone - Shout for help repeatedly. - Not alone - Tell helper to wait while you evaluate the child, you will give further instructions then.  FIRST AID OBJECTIVES: 1. To alleviate suffering 2. To prevent further injury or danger 3. To prolong life. ROLE OF FIRST AID: Bridge the gap between the victim and the health care. Not intended to compete with nor to take place the services of a doctor. First aid ends when the services of the doctor begins.  PRINCIPLES:  Survey the scene  Identify yourself as a trained rescuer  Do primary survey of the victim (head to toe)  Do secondary survey: injuries or problems that are not immediate threat to life WHAT TO DO:  Be calm and deliberate  Keep onlookers away  Keep victim comfortable and keep his spirits high  Tactfully encourage the victim  Minimize handling of the victim  Loosen all tight clothing  While awaiting medical assistance, follow these procedures: a. Check the victim's breathing. If the victim is not breathing, open the airway by opening the mouth and tilting the head back. If breathing does not resume spontaneously, maintain the open airway and perform mouth-to-mouth resuscitation. b. Check for heartbeat. If the victim does not have a heartbeat, perform cardiopulmonary resuscitation (CPR) if qualified. c. Check for injuries. Perform emergency first aid as outlined in this section.  Accident victims must not be moved unless it is essential to protect their lives or to prevent additional injury.  If the victim is conscious, reassure them. Keep them calm and quiet, and treat for shock while awaiting medical assistance.  Use personal protection to prevent transmission of bloodborne pathogens.  HEAT STRESS (STAMPEDE)  a. HEAT CRAMPS - painful muscle cramps are caused by the imbalance of salt and other minerals in body fluids. Drinking lightly salted water, tomato juice, or commercial "athletic" drinks in moderation will help maintain a proper balance of salt and other minerals.  b. HEAT EXHAUSTION is caused by inadequate water intake, salt and mineral losses, or both. It is characterized by wet, clammy skin; body weakness or extreme fatigue; unstable walk; nausea; and collapse. Heat cramps are often associated with heat exhaustion. Treatment includes rest in a cool place and drinking lightly salted fluids in moderation.  DEHYDRATION EXHAUSTION - may occur after several continuous days of work in the heat. If daily water losses are not replaced, progressive dehydration can severely reduce work capacity. Body weight loss is a key indicator of progressive dehydration. A loss of 2% or more is often accompanied by diminished work output. Exhaustion and collapse may follow weight loss exceeding 5%. Treatment includes fluid replacement and rest.  d. HEAT STROKE - results when the body's heat controls totally fail. This condition is characterized by: 1. Hot, dry skin. 2. High body temperature. 3. Mental confusion, delirium, loss of consciousness, convulsions or coma. Heat stroke is a medical emergency. Begin treatment immediately and obtain medical assistance. Brain damage and/or death may result if treatment is delayed. First treatment is to cool the victim quickly. One method is to soak the clothed victim with cold water and vigorously fan to promote evaporation. Continue until the victim's body temperature drops, then proceed to treat for shock. HEAT STRESS PREVENTION - The two important keys to preventing heat stress are physical fitness and acclimatization. 1. Fitness: Maintaining a high level of physical fitness is one of the best ways to protect yourself against heart stress. Workers who are physically fit adjust or acclimate to work in the heat almost twice as fast as others. Workers in poor physical condition who are also overweight are even more unsuited for work in the heat. Their greater weight produces more heat without a proportionate increase in surface area for cooling. 2. Replace fluids: Drink a lot of fluids to prevent dehydration: a. Drink 1 or 2 cups of juice or water before beginning work. b. Drink fluids frequently during each hour of work. c. Drink as much as you can at lunch and at the evening meal. d. Continue replacing fluids throughout the evening.  SEVERE BLEEDING Loss of blood TYPES OF BLEEDING: ARTERIAL: loss of blood from an artery: spurting, bright red and hard to control. VENOUS: loss of blood from a vein: steady, heavy, dark red, easier to control CAPILLARY: loss of blood from a capillary: flow is slow. Easy to control.  TYPES OF OPEN WOUND:  Abrasions: damage due to a scrape by a hard surface  Incision: damage due to a sharp object.  Lacerations: jagged or torn soft tissue due to sharp irregular object or edges  Puncture: small holes in the tissues  Avulsions: tissues torn or hanging from body  Amputations: complete removal of a body part.  Crushing injuries: part of the body is caught between heavy objects. Direct Pressure. Elevate  Pressure Point  tourniquet may be considered. The decision to apply a tourniquet is a decision to risk the sacrifice of the limb in order to save a life. Once the tourniquet is applied, do not loosen or remove it. Write the time and location that the tourniquet was applied on a note attached to the victim and have them transferred as quickly as possible to a medical facility. Immobilize  HEAD INJURIES  Concussion: A temporary loss of consciousness that results from a transient interruption of the brain's normal functioning.  Contusion: A bruising of the brain tissue. Actual small amounts of bleeding into the brain tissue.  Intracranial hemorrhage: Significant bleeding into a space or a potential space between the skull and the brain. This is a serious complication of a head injury with a high mortality rate due a rising intracranial pressure and the potential for brain herniation. Classification 1. epidural hematomas, 2. subdural hematomas, or 3. subarachnoid hemorrhages, depending on the site of bleeding. Primary Assessment 1. Airway: assess for vomitus, bleeding, and foreign objects. 2. Breathing: assess for abnormally slow or shallow res­pirations. An elevated PCO2 can worsen cerebral edema. 3. Circulation: assess pulse and bleeding.  Primary Interventions  1. Open the airway using the jaw-thrust technique with­- out head tilt. Oral suction equipment (to handle heavy vomitus) should be at hand.  2. Administer high-flow O2: the most common cause of death from head injury is cerebral anoxia.  3. Assist inadequate respirations with a bag-valve mask.  4. Control bleeding-do not apply pressure to the injury site: Apply a bulky, loose dressing. Do not attempt to stop the flow of blood or CSF from the nose or ears; apply a loose dressing if needed.  5. Initiate an intravenous (IV) line to run at a keep-vein­ open rate.  EYE INJURIES  a. If acid, caustic, or other irritating liquids get into eyes, flush eyes with large amounts of water. b. If objects get into eyes, place a sterile bandage over both eyes. c. If an object is stuck in the eye and protruding, place a cup over the eye and blindfold both eyes. d. In all eye injury cases, take the victim to medical help.  SPRAINS AND DISLOCATIONS  Elevate injured extremity. Apply cold packs to reduce swelling. Splint to prevent movement. Seek medical assistance. GENERAL INTERVENTIONS FOR SEVERLY INJURED PERSONS  Initiate IV line star volume replacement with Ringer’s lactate  Immobilize\e injury  Prepare pt. for surgery (close reduction or ORIF and wound care)  Antibiotics may be started  Elevate to prevent or limit swelling  Cold compress  Cover open fracture with a sterile dressing  Splint /immobilize joint above and below fracture  Handle part gently and as little as possible  Pain management  BLISTERS  is a collection of fluid in a bubble under the outer layer of skin WHAT TO DO:  apply a piece of silver aluminum duct tape or use a doughnut-shape mole skin secured by a tape  cover it with a slippery pad which absorbs friction and is secured by a tape IF BLISTER ON FOOT IS UNBROKEN & NOT VERY PAINFUL:  cut & apply a doughnut shaped hole in a several layers of moleskin or mole foam to fit around the blister secured by a tape cover it with “Spenco Second Skin” and secured by tape.  IF BLISTER ON FOOT IS BROKEN: clean the areas with soap and water drain all fluid out of blister by making several small holes at the base of the blister with a sterilized needle. Press the fluid out. Do not remove the blister’s roof unless it is torn apply antibiotic ointment and cover it with a non-stick pad or gauze pas. change dressing daily and check for signs of infection NOSE INJURIES: - most nosebleeds are self limited & seldom require medical attention  Types: 1. Anterior (90%); bleeds out of one nostril 2. Posterior: massive bleeding backward into the mouth or down the back of the throat. Both nostrils bleed. WHAT TO DO:  keep in a sitting-up position to reduce blood pressure  keep the victim’s head bent slightly forward  pinch both nostrils with steady pressure for 5 minutes. Breathe through their mouth & spit out any accumulated blood.  if bleeding continues, have he victim gently blow the nose to remove any clots & excess blood & to minimize sneezing. This allows new clots to form. The press the nostrils for 5 minutes.  use other methods such as using a roll of gauze or using ice pak over the nose bridge.  if the victim is unconscious, place the victim on his side to prevent inhaling of blood, seek medical attention  MUSCLE INJURIES  “RICE” R: REST (not to move frequently to contain oxygen) I: ICE (20-30 minutes every 2-3 hours during 1st 24-48 hours. C: COMPRESSION (elastic bandage for 18-24 hours) E: ELEVATION: minimizes swelling  00:00 Stings and Bites A sting happens when an insect injects venom into your skin. The venom travels through the bug’s stinger. If you get stung, you’ll feel pain. Your skin may turn red or swell at the site of the sting. In some cases, people who are allergic to the venom can have a life-threatening reaction. Doctors call this anaphylaxis. 00:00 Among the most common stinging insects are: Wasps (including hornets and yellow jackets) Bees Fire ants An insect bite happens when a non- venomous bug pierces your skin and feeds on your blood. This may cause a bump (“papules”) to form. The telltale sign is intense itching. Examples of biting insects include: Mosquitoes Fleas Bedbugs Lice Insect and Spider Bite Symptoms -Most insect bites cause only minor irritation, with symptoms like swelling at the site of the bite or itching or burning. You might also feel numbness or tingling. -If you’ve been bitten by a venomous spider, you may notice any of the following: Intense pain at the site of the wound Stiffness or joint pain Muscle spasms Abdominal pain, nausea, or vomiting Fever or chills Difficulty breathing or swallowing A wound that spreads or turns into a sore (tissue around the wound might also die) Dizziness Difficulty speaking Convulsions Allergic Reactions to Stings and Bites -Insect stings and bites can cause severe allergic reactions. This is called “anaphlaxis.” -Spider bite can cause an allergic reaction that causes “anaphylactic shock.” It can be fatal. -Call 911 if you have any of these symptoms: Rapid swelling of the lips, tongue, throat, or around the eyes Difficulty breathing Wheezing or hoarseness Severe itching, cramping, or numbness Dizziness A reddish rash or hives Stomach cramps Loss of consciousness -If you have any of these things and have epinephrine on hand, don’t hesitate to use it, even if you’re not sure your symptoms are caused by allergies.  SHOCK as inadequate tissue perfusion resulting from failure of one or more of following: The heart – pump failure Blood volume Arterial resistance vessels Capacity of venous beds  Classifications of Shock: 1. Hypovolemic shock – occurs when significant amount of blood is lost from intravascular space resulting from hemorrhage, burns, or fluid shifts 2. Cardiogenic shock – failure of heart as a pump from MI, serious cardiac dysrhythmias 3. Septic shock – result of bacteria and their release of their products in the blood 4. Neurogenic shock – from decreased sympathetic control of blood vessels from defect of vasomotor center of brain stem or blood vessels such as in brain injury, depressant actions of drugs, anesthesia, hypoxia  Hypoglycemic shock – from lack of glucose or insulin reaction  Spinal shock - occurs in persons with spinal cord injury 5. Anaphylactic shock – massive vasodilatation, pooling of blood I peripheral blood  vessels, and increased capillary permeability from systemic anaphylaxis from  release of vasodilator substance such as histamine  GENERAL INTERVENTIONS Administer O2 to maintain PaO2 at 80-100 mmHg Fluid resuscitation: Lactated Ringer’s , Fresh whole blood if massive blood loss, platelets and cor\agulation factors Insert indwelling urinary catherter: record urinary q15 to 30 min: reveals adequacy of kidney and visceral perfusion- mainatain normal fluid level Maintain pt. on supine position with legs elevate ECG monitoring Monitor vital signs, and laboratory data Maintain normothermia (state of normal temperature) Pharmacologic interventions  Inotropic in cardiogenic shock: Isoproterenol, digoxin, dobutamine-  Vasopressors: Dopamine, Norepinephrine  Antibiotics – broad spectrum for septic shock  B - bicarbonate (Na) (antacid, systemic & urine alkalinizer)  E - epinephrine or adrenalin (cardiac stimulant)  C - calcium carbonate (antacid, electrolyte)  A - atropine sulfate (anticholinergic) – increases HR  L - lidocaine or xylocaine(anti-arrhythmic/anesthetic)  M - magnesium sulfate (anticonvulsant)  FAINTING  numerous reasons cause blood interruption; e.g. emotional distress and standing too long without moving  What to do:  prevent the person from falling  have the person lie down & raise the legs 8-12 inches  loosen tight clothing, especially from around the neck  place a cool, wet cloth on forehead  if fainting has happened:  check the ABCHs.  lay the victim down & raise the legs 8-12 inches unless a head injury is suspected from the victim falling.  loosen tight clothing & belts  if the victim fell, check for injuries  place a cool, wet cloth on forehead.  seek medical attention.  Don’ts: Do not splash or pour water on the victim’s face do not use smelling salts or ammonia inhalants do not slap the victim’s face as an attempt to revive him or her do not give the victim anything to drink until fully recovered.  Poisoning - Poisoning is injury or death due to swallowing, inhaling, touching or injecting various drugs, chemicals, venoms or gases. Many substances — such as drugs and carbon monoxide - when a toxic substance (poison) makes you sick or harms you. Poisons can come from plants, animals, household cleaners and chemicals, medications, carbon monoxide and more. What are the effects of poisoning? The effects of poisoning range from mild to severe. Some cases are fatal. How poisoning affects you depends on many factors, including: The amount that enters your body. Too much of anything can be poisonous. Even oxygen, in high concentrations, can make you sick. The more toxic something is, the less it takes to make you sick or harm you. Poisons are generally more dangerous in larger quantities. The type of poison. Certain types of poison cause mild symptoms that go away with at-home care. Other substances are more likely to cause severe illness. How it enters your body. Poisons can enter your body through your skin, mouth, nose or eyes. Swallowing a toxic substance (like a household cleaner) often causes more harm than touching it with your skin. How long you’re exposed to it. A poisoning can be either acute or chronic. An acute exposure might just be seconds or minutes. A chronic exposure involves long- term exposure to a poison. Chronic exposures often happen on the job, especially in mining, factory settings or agriculture. How soon you get treatment. Quick treatment may limit or stop the effects of poisoning entirely. - Poisons affect children differently than adults. Children are smaller, so a dose that wouldn’t harm you could be deadly to them. People with underlying medical conditions might also get sicker from poisons or have a harder time recovering. What are the symptoms of poisoning? The signs and symptoms of poisoning vary according to: The amount and type of poison. Your age and overall health. How the poison gets into your body. For example, a poison that splashes into your eye causes eye-related symptoms. Swallowed poisons cause digestive symptoms. The duration of exposure (acute vs. chronic). Symptoms of acute poison exposure -There are many possible symptoms of acute poisoning. These can affect your whole body and/or individual parts. Symptoms may show up immediately. Or, there might be a delay of hours or days. -If you think you might be experiencing poisoning symptoms, call poison control or your local emergency services number. Symptoms can include: Changes in body temperature. Changes in heart rate. Chest pain Confusion. Cough, possibly with blood. Diarrhea, nausea and/or vomiting. Dizziness, weakness or fainting. Eye pain, redness, swelling or tearing. Headache. Severe burning in your eyes, nose, throat and airways. Skin rash, redness, pain, burning or stinging. Stomach pain and cramping. Difficulty of breathing. Trouble seeing or loss of vision What causes poisoning? Poisoning happens when you’re exposed to enough of something to make you sick or harm you. For example: You inhale a poison that’s in the air around you. You eat or drink a substance that contains a poison. A poison gets into your eye. A poison touches your bare skin and gets absorbed. An animal or insect bites or stings you and injects venom.  Drowning and Near Drowning - Drowning is defined as death by asphyxia due to submersion in a liquid medium. - Near-drowning is defined as immediate survival after asphyxia due to submersion.  Foreign-Body Airway Obstruction  CHOKING a. If victim is coughing or if air exchange is satisfactory, let the victim continue to cough. b. If a complete obstruction is present and breathing ceases, attempt to dislodge stuck particles. By grabbing the victim from behind, make a fist with your hand, and place it below the ribs. Grasp your fist with the other hand, and press firmly in and up to dislodge particles. Repeat until obstruction is removed. c. If the victim loses consciousness, lay the person on his back and place both of your hands palm down on the victim's upper abdomen. Give several firm upward shoves to attempt to dislodge obstructions. If breathing does not return spontaneously after the blockage is cleared, begin artificial respiration. SUBSTANCE/DRUG ABUSE  Substance Abuse – use of specific substances that are intended to alter mood or behavior  Drug Abuse – use of drugs other than their legitimate purposes. Primary Assessment and Interventions  Assess presence of adequacy of respirations  Attain control of airway, ventilation, and oxygenation  Intubate if necessary if severely distressed  CPR in absence of heartbeat  CNS Stimulants :amphetamines, cocaine, ecstacy  S/s: palpitation, feeling of impending doom, tachycardia, hypertension, dysrhythmias, myocardial ischemia/infarction, euphoria, agitation, combativeness, confusion, hallucination, paranoia, aggressive or violent behavior, suicide attempts, hyperpyrexia, seizures.  When drug wears off: depression, exhaustion, irritability, sleeplessness  Interventions: Secure ABCs, Monitor ECG and provide oxygen for ischemia, sedate as necessary, antiarrhythmics for dysrhythmias, Diazepam for seizure, close monitoring of homodynamic status, IV fluids as indicated  Hallucinogens: (Lysergic acid diethylamide[LSD], Psilocybin mushroom, Jimson weed seeds) - an acid known for its psychological effects, which can include altered thinking processes, closed- and open-eye visuals, synesthesia, an altered sense of time and spiritual experiences.  S/S: Marked anxiety bordering on panic, confusion, incoherence, hyperactivity, hallucinations, hazardous behavior, convulsions coma, circulatory collapse, death, flashback months to years after initial drug abuse  Interventions: Talk with patient by understanding with he has gone through, reduce fears, establish contact with reality, reduce sensory stimuli, encourage to keep eyes open, stay with pt., monitor for hypertensive crisis and signs of trauma, sedate if hyperactivity cant be controlled, placed in a protected environment  Narcotics (Heroin, Morphine, Codeine)  S/s: hypotension, respiratory depression leading to apnea, miosis, drowsiness, then, stupor, and coma  Interventions: Administer Naloxone (Narcan) 0.4 to 2 mg IV or via ET tube, open airway, protect from harm Sedatives (Barbiturates [aminobarbital], diazepam, hypnotics)  S/s: Incoodrination, ataxia, impaired thinking and speech, lethargy to coma, early miosis then fixed dilated pupils, hypoventilation, hypotension, hypothermia, decreased reflexes  Interventions: administer flumazenil to reverse or diminish effects of benzodiazepines; activated charcoal, protect airway, ringer’s lactate and vasopressors for hypotension  Alcohol (Intoxication when blood levels are >100 mg/dl; >400 mg/dl is a medical emergency) S/s: Slurred speech, incoordination, ataxia, belligerent behavior from stupor to coma, odor of alcohol on breath and clothing, respiratory depression. Interventions: Protect airway, monitor CNS and respiratory depression, check for head injury and other trauma and organic diseases, administer IV fluids, magnesium sulfate to reduce risk for seizures, thiamine to prevent Wernickes-Korsakoff syndrome), glucose for hypoglycemia.  ADVANCE CARDIAC LIFE SUPPORT Definition: - is a set of life-saving protocols and skills that extend Basic life support to further support the circulation and provide an open airway and adequate ventilation (breathing). ALS assumes that basic life support (bag- mask administration of oxygen and chest compressions) are administered. actual cardiac arrest has been established relies on the monitoring of the electrical activity of the heart on a cardiac monitor. Depending on the type of cardiac arrhymia ---defibrillation is applied.  Medication is administered.  Oxygen is administered  Endotracheal intubation may be attempted to secure the airway.  At regular intervals, the effect of the treatment on the heart rhythm, as well as the presence of cardiac output, is assessed. While CPR is given (either manually, or through automated equipment such as Auto Pulse), team consider eight forms of potentially reversible causes for cardiac arrest. (6H’s and 4T’s) 6 H’s Hypoxia: low oxygen levels in the blood Hypovolemia: low amount of circulating blood, either absolutely due to blood loss or relatively due to vasodilation Hyperkalemia or hypokalemia: disturbances in the level of potassium in the blood, and related disturbances of calcium or magnesium levels. Hypothermia/Hyperthermia: body temperature not maintained Hydrogen ions (Acidosis) Hypoglycemia: Low blood glucose levels 4T’s Tension pneumothorax: tear in the lung leading to collapsed lung and twisting of the large blood vessels Tamponade: fluid or blood in the pericardium, compressing the heart Toxic and/or therapeutic: chemicals, whether medication or poisoning Thromboembolism and related mechanical obstruction (blockage of the blood vessels to the lungs or the heart by a blood clot or other material) Sodium bicarbonate 2 mEq/kg IV bolus  may repeat half-dose every 10 minute to correct acidosis but should be used with caution and with ABG analysis to avoid precipitating alkalosis BURNS A burn is a type of injury to flesh or skin caused by heat, electricity, chemicals, friction or radiation. - Superficial or first-degree burns- burns that affect only the superficial skin - Partial-thickness or second-degree burn - damage penetrates into some of the underlying layers. - Full-thickness or third-degree burn- the injury extends to all layers of the skin. - Fourth-degree burn additionally involves injury to deeper tissues, such as muscle or bone.  Treatment - depends on the severity of the burn.  Superficial burns - managed with simple pain relievers  Major burns may require prolonged treatment in hospital. Cooling with tap water may help relieve pain and decrease damage but prolonged exposure to cold water may result in low body temperature.  Partial-thickness burns - cleaning with soap and water, followed by dressings. Blisters -reasonable to leave them intact.  Full-thickness burns -require surgical treatments, such as skin grafting.  Extensive burns often require large amounts of intravenous fluid, because the subsequent inflammatory response causes significant capillary fluid leakage and edema. The most common complications of burns involve infection. Special Protective Equipment  CATEGORIES OF PROTECTIVE EQUIPMENT Level A : Self contained breathing apparatus (SCBA) and vapor-tight chemical resistant suit, glorus and boots. Level B : High level of respiratory protection purified respirator, cover all with splash hood, and chemical resistant glorus and boots Level D: Typical work uniform Post Traumatic Stress Disorder(PTSD) - A condition that generates waves: - Anxiety - Anger - Aggression - Depression - Suspicion *That threaten the persons sense of self and interfere with daily functioning  *Some events that place a person at risk for PTSD: - Rape - Fire - Family violence - Earthquake - Torture - Military combat - Terrorism * It has been postulated that people with PSTD lose the ability to control their response to stimuli. * The resulting excessive arousal ca increase overall Body metabolism and Trigger Emotional Reactivity Manifestations: 1. Has difficulty sleeping 2. Has an exaggerated startle response 3. Is excessive vigilant Symptoms Can Occur Hours to years the Trauma is Experienced. - Acute – the experience of symptoms for less than 3 month period. - Chronic – experience of symptoms longer than 3 months *In case of delayed PTSD, up to 6months may elapse between the trauma and manifestation of symptoms Nursing Implications: - It is important that nurses considerwhich of their patients are at risk for PTSD and be knowledgeable about the common symptoms associated with it. - The sensitivity and caring of the nurse creates the interpersonal relationship necessary to work with patients who have PTSD. Essential components of Treatment for Patient with PTSD. 1. Establishing a trusting relationship 2. Addressing & working through the trauma experience 3. Providing education about the coping skills need for recovery and self-care Intravenous Therapy 90-95% of patients in the hospital receive some type of intravenous therapy.  Veins of the Upper Extremities  Digital Vessels -Along lateral aspects fingers, infiltrate easily, painful, difficult to immobilize and should be your LAST RESORT  Metacarpal Vessels -Located between joints and metacarpal bones (act as natural splint) -Formed by union of digital veins -Geriatric patients often lack enough connective / adipose tissue and skin turgor to use this area successfully  Veins of the Upper Extremities  Cephalic (Intern’s Vein) -Starts at radial aspect of wrist -Access anywhere along entire length (BEWARE of radial artery/nerve)  Medial Cephalic (“On ramp” to Cephalic Vein) -Joins the Cephalic below the elbow bend -Accepts larger gauge catheters, but may be a difficult angle to hit and maintain  Purposes of IV Therapy To provide parenteral nutrition To provide avenue for dialysis/apheresis To transfuse blood products To provide avenue for hemodynamic monitoring To provide avenue for diagnostic testing To administer fluids and medications with the ability to rapidly/accurately change blood concentration levels by either continuous, intermittent or IV push method.  Starting a Peripheral IV  Finding a vein can be challenging - Go by “feel”, not by sight. Good veins are bouncy to the touch, but are not always visible. - Use warm compresses and allow the arm to hang dependently to fill veins. - A BP cuff inflated to 10mmHg below the known systolic pressure creates the perfect tourniquet. Arterial flow continues with maximum venous constriction. - If the patient is NOT allergic to latex, using a latex tourniquet may provide better venous congestion - Avoid areas of joint flexion - Start distally and use the shortest length/smallest gauge access device that will properly administer the prescribed therapy - (BE AWARE: Blood flow in the lower forearm and hand is 95ml/min) Complications of IV Therapy 1. Phlebitis - an inflammation of the vein, is among the most common complications of IV therapy. - Possible causes of phlebitis may be chemical (caused by the substance being infused), mechanical (movement of the catheter while inside the vein) or bacterial (either intrinsic or extrinsic) - When a patient develops signs of phlebitis (warmth, tenderness, redness around the site or a swollen or visibly raised vein) - Because phlebitis is an inflammatory response by the vein to trauma, symptoms may not become evident until well after removal of the device.  2. Occlusion: Non-thrombotic or thrombotic - Another potentially dangerous complication that can arise during IV therapy is thrombotic or non-thrombotic occlusion. An occlusion is an obstruction that restricts or prevents the administration of fluids through the PIVC. - Thrombotic occlusions are blood clots that develop in or around the catheter tip or in the surrounding vessel. - Non-thrombotic occlusion can be due to trauma to the vein wall from IV catheter movement once inside the vessel. Occlusions represent a significant threat to patient outcomes and require high cost interventions.  3. Infiltration - is the leaking of IV fluid into the tissue surrounding the vein. This occurs when IV fluids continue to be delivered even though the tip of the catheter is no longer in the vessel or is blocked. Although most infiltrations do not cause tissue damage, the potential for serious harm does exist. When a large amount of IV solution enters the tissues, nerve compression injuries from compartment syndrome can result. An infiltration is likely to cause disruption in IV therapy, patient discomfort and require the restart of a PIVC in a different location, consuming nursing time and increasing the cost of supplies.  4. Extravasation - is an infiltration involving the leakage of vesicant fluids into the tissues. - Vesicants are substances known to be more caustic than regular IV fluids, and are capable of causing physical harm unless they are kept strictly in the vascular space. These chemical or drug substances can cause blistering and burning in the tissue and, although small extravasations may not result in patient injury, large amounts of vesicant fluids can cause severe damage. 5. Infection IV catheter-related sepsis can occur from poor catheter insertion technique or when phlebitis progresses. Bacteria from an IV site can migrate through the bloodstream, causing fever, chills, malaise and an elevated white blood cell count. When IV infections are present, appropriate interventions include discontinuing the infusion, removing the PIVC, and instituting other local or medical interventions as necessary to treat the infection. All of these actions result in an interruption of therapy with associated consequences. Management for the IV Complications 1. Remove IV cannula and reinsert appropriate vascular access device in new location 2. Apply warm moist compress (i.e. body temperature) to site for 20 mins, 6 hourly for 24 hours for non cytotoxic drugs only 3. Use smallest gauge, cannula in largest vein possible (refer to IV package), if 2 or 3 attempts failed 4. Dilute irritating solutions to acceptable dilutions in consultation with pharmacy 5. Decrease infusion rate for the 1st 30 mins to 1 hours after the insertion. 6. Discuss with doctor different routes in administering of different medications for the patient 7. Document the above actions and assessments