Nursing Care of Clients in Emergency Situations - Medical Emergencies PDF

NURSING CARE OF CLIENTS IN EMERGENCY SITUATIONS- MEDICAL EMERGENCIES Group 3 1  AIRWAY, BREATHING, CIRCULATION 2  AIRWAY An open airway allows air to enter the lungs for the person to breathe. If the way is blocked, the person cannot breathe....

NURSING CARE OF CLIENTS IN EMERGENCY SITUATIONS- MEDICAL EMERGENCIES Group 3 1  AIRWAY, BREATHING, CIRCULATION 2  AIRWAY An open airway allows air to enter the lungs for the person to breathe. If the way is blocked, the person cannot breathe. 3  BREATHING While Maintaining an open airway, quickly check an unconscious person for breathing by doing the Look, Listen, and Feel (LLF) technique for no more than 10 seconds. 4 CIRCULATION Pulse Bleeding Shock Skin color and temperature 5  FOREIGN BODY OBSTRUCTION 6 FOREIGN BODY OBSTRUCTION a common and serious issue with significant morbidity and mortality. Choking can result from both food and non-food items, leading to varying degrees of asphyxiation or oxygen deprivation. 7 FOREIGN BODY OBSTRUCTION CAUSES: 1. Food-related 2. Foreign-objects 3. Medical of Physical Condition 4. Behavioral 5. Aspiration 6. Developmental Factors 8 UPPER RESPIRATORY TRACT 9 UPPER RESPIRATORY TRACT NOSE NASAL CAVITY PHARYNX LARYNX MOUTH 10  UPPER RESPIRATORY TRACT MASS OR EDEMA partial or complete obstruction NOSE NASAL CAVITY PHARYNX LARYNX MOUTH 11 FOREIGN BODY OBSTRUCTION TYPES: 1. Partial Obstruction 2. Complete Obstruction 12 PARTIAL OBSTRUCTION SIGNS/SYMPTOMS Cough Gag Choke Drool Dyspnea Hoarse when speaking Inspiratory Stridor 13 COMPLETE OBSTRUCTION SIGNS/SYMPTOMS Unable to: COUGH, SPEAK, BREATHE Cyanotic Unresponsive 14 FOREIGN BODY OBSTRUCTION ASSESSMENT: Airway Status Assess for signs and symptoms. Visual Inspection Look for visible obstructions. Do not perform a blind finger sweep. 15 FOREIGN BODY OBSTRUCTION ASSESSMENT: Breathing Observe chest movement. Circulation Assess for signs of hypoxia: Pallor or cyanosis. 16 FOREIGN BODY OBSTRUCTION DIAGNOSES: Ineffective Airway Clearance related to obstruction of the airway by a foreign body. as evidenced by: Inability to speak or cough. Absent or diminished breath sounds. Cyanosis or choking gestures. 17 FOREIGN BODY OBSTRUCTION DIAGNOSES: Impaired Gas Exchange related to complete or partial airway blockage impairing oxygen and carbon dioxide exchange. as evidenced by: Decreased oxygen saturation. Cyanosis of lips, skin, or nail beds. Altered mental status. 18 FOREIGN BODY OBSTRUCTION PLANNING: Removal of Upper Airway Obstruction Restoration of Clear Airway Return to Normal Breathing Pattern 19  FOREIGN BODY OBSTRUCTION INTERVENTIONS: Heimlich Maneuver Children Adults and Children (< 1 y.o.) (> 1 y.o.) 5x Back blows followed by 5x Abdominal Thrusts 5x Chest Thrusts 20 FOREIGN BODY OBSTRUCTION INTERVENTIONS: Laryngoscopy Removed by Forceps or Suction. 21 FOREIGN BODY OBSTRUCTION INTERVENTIONS: Cardiopulmonary Resuscitation 22 FOREIGN BODY OBSTRUCTION PHARMACOLOGICAL MANAGEMENT Epinephrine for anaphylaxis reaction Oxygen Therapy for acute respiratory distress 23 FOREIGN BODY OBSTRUCTION PHARMACOLOGICAL MANAGEMENT Antibiotics piperacillin-tazobactam, meropenem for aspiration pneumonia Anxiolytics lorazepam, diazepam for anxiety 24 FOREIGN BODY OBSTRUCTION PHARMACOLOGICAL MANAGEMENT Corticosteroids methylprednisolone, dexamethasone for inflammation or injury to the airways Bronchodilators albuterol, salmeterol for bronchospasm or wheezing 25 FOREIGN BODY OBSTRUCTION PATIENT AND FAMILY EDUCATION Prevention Strategies Childproofing Safe eating habits Toy-safety Immediate Interventions Heimlich Maneuver 26 FOREIGN BODY OBSTRUCTION EVALUATION 1. The airway is clear and breathing is restored. 2. Vital signs are stable (oxygen saturation is ≥ 95%). 3. No signs of infection or further complications. 4. The patient and family understands the choking prevention strategies. 27 INHALATION INJURY 28 INHALATION INJURY refers to damage to the respiratory tract or lung tissue from heat, smoke, or chemical irritants carried into the airway during inspiration 29 TYPES OF INHALATION INJURY THERMAL INJURY CHEMICAL INJURY SMOKE INHALATION 30 THERMAL INJURY refers to damage caused by the inhalation of hot gases, steam, or flames. It primarily affects the upper airway because the large heat capacity of air dissipates the heat before it can reach the lower respiratory tract. 31 CHEMICAL INJURY occurs when toxic substances, fumes, or vapors are inhaled, causing damage to the respiratory tract. These injuries can affect both the upper and lower airways, depending on the type and solubility of the chemical involved. 32 SMOKE INHALATION caused by breathing in the complex mixture of hot gases, particulate matter, and toxic chemicals released during a fire. It is one of the leading causes of death in fire-related injuries and can result in both thermal and chemical damage to the respiratory system. 33  EFFECTS OF INHALATION INJURY ON THE RESPIRATORY TRACT 1. Upper Airway Thermal burns cause swelling, redness, and tissue damage in the mouth, throat, and larynx. Can lead to airway obstruction and difficulty breathing. 2. Lower Airway and Lungs Toxic gases and smoke cause inflammation, bronchospasm, and fluid accumulation (pulmonary edema). Results in impaired oxygen exchange and lung function. 3. Mucociliary Clearance Toxins damage the mucociliary escalator, reducing mucus clearance. Increases risk of infection and mucus plugging. 4. Chemical Injury Combustion products (e.g., carbon monoxide, cyanide) impair oxygen delivery. Can lead to hypoxia and tissue damage. 34  INHALATION INJURY SIGNS AND SYMPTOMS Upper Airway Signs: Hoarseness, stridor, or wheezing. Sore throat or difficulty swallowing. Swelling of the face or neck. Lower Airway Symptoms: Cough (may produce black or sooty sputum). Dyspnea (shortness of breath) or tachypnea (rapid breathing). Chest tightness or wheezing. 35  INHALATION INJURY SIGNS AND SYMPTOMS Physical Signs Soot or burns around the mouth and nose. Singed nasal hairs. Visible burns in the mouth or throat. 36  INHALATION INJURY NURSING DIAGNOSIS 1. Ineffective Airway Clearance Cause: Airway edema, soot, mucus obstruction. Interventions: Assess for stridor and hoarseness. High Fowler’s position and humidified oxygen. Prepare for intubation if obstruction worsens. 37  INHALATION INJURY NURSING DIAGNOSIS 2. Impaired Gas Exchange Cause: Carbon monoxide or cyanide poisoning, alveolar damage. Interventions: Administer 100% oxygen via a non-rebreather mask. Monitor oxygen saturation and ABGs. Use antidotes for confirmed toxic exposures. 38  INHALATION INJURY ASSESSMENT & DIAGNOSTIC TESTS 1. History and Physical Examination 2. Laboratory Tests Arterial Blood Gas (ABG) Carboxyhemoglobin Levels Cyanide Levels Complete Blood Count (CBC) 3. Imaging Studies Chest X-ray Chest CT Scan 4. Bronchoscopy 39  INHALATION INJURY PHARMACOLOGICAL MANAGEMENT 1. Oxygen Therapy 2. Antidotes for Toxic Gas Exposure Hydroxocobalamin: For cyanide poisoning. Sodium Thiosulfate: Alternative for cyanide poisoning. 3. Bronchodilators Examples: Albuterol, Ipratropium. Relieves bronchospasms and improves airflow. 4. Anti-Inflammatory Agents Corticosteroids, example: Dexamethasone Reduces airway inflammation. 40  INHALATION INJURY PATIENT EDUCATION 1. Medication Adherence 2. Hydration and Nutrition 3. Avoidance of Respiratory Irritants 41 ANAPHYLAXIS 42  ANAPHYLAXIS is a common medical emergency and a life-threatening acute hypersensitivity reaction. It can be defined as a rapidly evolving, generalized, multi-system allergic reaction. 43  CAUSES Food allergies Medications Stinging insects Medications Tree nuts (like walnuts, Cow’s milk Latex hazelnuts, Brazil nuts) Eggs Peanuts Wheat Shellfish such as Seeds (like sesame seeds shrimp and lobster and sunflower seeds) 44  CAUSES Food allergies Medications Stinging insects Certain medications and substances, Medications Latex, found in items such as including penicillin, nonsteroidal anti- Latex disposable gloves, catheters inflammatory drugs (NSAIDs) and adhesive tapes. Insect stings from bees, wasps, hornets. 45  RISK FACTORS Previous Anaphylaxis Allergy History Asthma Family history of Anaphylaxis Underlying Health Conditions 46  SIGNS and SYMPTOMS 47  STAGES Of ANAPHYLAXIS Stage one: Mild anaphylaxis Stage two: Moderate anaphylaxis Stage three: Severe anaphylaxis Stage four: Life-threatening anaphylaxis 48 DIAGNOSTIC ASSESSMENT 1. History a.) Particular foods b.) Latex c.) Medications d.) Insect Stings 2.Blood Test 3. Skin Test 49  NURSING DIAGNOSIS 1. Ineffective Airway Clearance related to swelling (angioedema) and bronchoconstriction secondary to an allergic reaction. 2. Impaired Gas Exchange related to decreased oxygen supply due to airway obstruction or bronchospasm. 50  PLANNING Goals: 1. Maintain a patent airway to ensure adequate oxygenation. 2. Stabilize blood pressure and prevent cardiovascular collapse. 3. Reduce the severity of the allergic reaction. 4. Prevent further exposure to the allergen and educate the patient on anaphylaxis management. 51  IMPLEMENTATION 1. Administer Epinephrine IM (First-line treatment): Dose: 0.3–0.5 mg intramuscularly, repeated every 5-15 min if necessary 2. Ensure Airway Patency 3. Provide Oxygen Therapy 4. Start IV Access and Fluid Resuscitation 5. Continuously monitor Vital signs (BP, HR, RR) Oxygen saturation Level of consciousness 52  PHARMACOLOGICAL TREATMENT Epinephrine (adrenaline) -to reduce the body's allergic response 53  PHARMACOLOGICAL TREATMENT Oxygen - to compensate for increased oxygen demand 54  PHARMACOLOGICAL TREATMENT A beta-agonist (such as albuterol) -to relieve breathing symptoms Intravenous (IV) -antihistamines and cortisone 55 DIET AND NUTRITION FOODS TO AVOID Nuts Seafood Dairy products Processed or packed food - (unless labeled allergen free) 56 PATIENT EDUCATION 1.Teach the patient to avoid identified allergens. 2. Instruct on the proper use of an epinephrine auto-injector (e.g., EpiPen). 3. Educate on recognizing early signs of an allergic reaction and when to seek emergency care. 57  EVALUATION 1. PATIENT MAINTAINS A PATENT AIRWAY AND OXYGEN SATURATION ≥95%. 2. BLOOD PRESSURE STABILIZES, AND CARDIOVASCULAR FUNCTION IS RESTORED. 3. SYMPTOMS OF ANAPHYLAXIS RESOLVE WITHOUT RECURRENCE. 4. PATIENT AND FAMILY DEMONSTRATE UNDERSTANDING OF PREVENTION AND MANAGEMENT STRATEGIES. 58 HEAD INJURY 59  HEAD INJURY A head injury is any trauma to the scalp, skull, or brain, ranging from a mild bump or bruise to severe brain injury 60  HEAD INJURY Common Causes: Road traffic accidents (RTA) Falls Sports injuries Violence or assault Industrial or workplace accidents 61  THORACIC EMERGENCY 62  INTRODUCTION Thoracic emergencies are acute, life threatening conditions involving the chest cavity and its vital organs, such as lungs, heart and major blood vessels. Conditions include pneumothorax, hemothorax and flail chest. 63 TYPES OF THORACIC INJURIES: PNEUMOTHORAX PNEUMOTHORAX HEMATHORAX HEMOTHORAX FLAIL FLAILCHEST CHEST 64  WHAT IS PNEUMOTHORAX? Air fills the pleural space, which can cause one or both lungs to collapse. 65  WHAT IS HEMOTHORAX? Blood accumulates in the pleural space. 66  WHAT IS FLAIL CHEST? A part of the rib cage detaches due to multiple rib fractures. 67  CAUSES Motor Vehicle Cardiac Conditions Accidents Myocardial Infarction Cardiac Tamponade Pulmonary Embolism Severe Pneumonia 68  SIGNS AND SYMPTOMS Hypotension Pallor and Diaphoresis Shortness of Breath Delayed Capillary Refill Hypoxia 69  NURSING DIAGNOSIS 1. Ineffective Breathing Pattern related to chest trauma or airway obstruction. 2. Impaired Gas Exchange related to altered ventilation-perfusion ratio. 3. Acute Pain related to trauma or pleural inflammation. 70  PLANNING 1. Goal: Stabilize the patient's condition, restore effective breathing, and address underlying causes. 2. Patient will maintain a respiratory rate within normal limits (12-20 breaths/min). 3. Patient will demonstrate effective oxygenation (SpO₂ > 92%) and maintain ABG values within normal limits. 4. Pain levels will be reduced to