Emergency 3

8/13/2019 Emergency 3

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• ADULT RESPIRATORY DISTRESSSYNDROME (ARDS) – a form ofpulmonary edema that causes acuterespiratory failure resulting fromincreased permeability of the alveolo-

capillary membrane. Fluid accumulates inthe lung interstitium, alveolar spaces, andsmall airways, causing the lungs to stiffen.Effective ventilation is thus impaired,

prohibiting adequate oxygenation ofpulmonary capillary blood.



ASSESSMENT FINDINGS • rapid, shallow breathing

• dyspnea• tachycardia• hypoxemia• intercoastal and suprasternal retractions

• crackles and rhonchi• restlessness• apprehension

• mental sluggishness• motor dysfunction



INTERVENTIONS • Mechanical Ventilation – improves the gas

exchange between the alveoli andpulmonary capillaries by delivering tidalvolume under positive pressure (while thepatient is sedated), expanding the alveoli,halting the atelectasis and an adequate gasexchange resumes. Types of ventilatorsused for patients with ARDS include –

• Volume Cycled Ventilator – ends inspiration after apreset volume

• High Frequency Jet Ventilator – delivers a smalltidal volumes (up to 300 ml) at a respiratory rate of60 to 100 beats per minute – the small tidal volumeintensifies in the patient’s airway forcing air into thealveoli – as a result the exhaled tidal volume exceedsthe jet volume delivered.



• Drug Therapy – include he following– Sedatives Neuromuscular Blockers – to

paralyze the patient on the ventilator to keep

them from fighting the ventilator – to helpminimize oxygen consumption.– Steroids in high doses – to reduce inflammation– Antibiotics – depending on the culture and

sensitivity tests

• Fluid Management – to maintain circulatingblood volume

• Pulmonary Hygiene – suctioning, chestpercussion, etc.

• Nutrition – proper diet to preventprogressive weakness of the respiratorymuscles



NURSING DIAGNOSES • Impaired Gas Exchange related to interstitial

and alveolar edema

• Potential For Fluid Volume Excess related tointerstitial and alveolar edema

• Altered Nutrition, Decreased – Less Than TheBody Requirements related to a heightened body

metabolism and inability to eat as a result ofdyspnea and hypoxemia • Self-Care Deficits related to mental

sluggishness and motor dysfunction • Knowledge Deficit related to inadequate

information regarding the disease process,treatment options

• Ineffective Coping related to the diseaseprocess, or the inability to communicate

while on a ventilator.



NURSING INTERVENTIONS • Frequently assess the patient’s respiratory

status-auscultate breath sounds, watch for

dyspnea, etc.• Observe and document the hypoxemic patient’sneurologic status – LOC, mental sluggishness

• Maintain a patent airway by suctioning, usingsterile, non-traumatic technique

• Closely monitor heart rate and rhythm, and bloodpressure• Monitor serum electrolyte levels and correct

imbalances – MIO, weigh patient daily• Check ventilator settings frequently, and empty

condensation from tubing promptly to ensuremaximum oxygen delivery• Monitor ABG studies. Give sedatives as

needed to reduce restlessness. Repositionthe patient





• THYROID STORM – an extremeexaggeration of the clinical manifestationof hyperthyroidism; a life-threateningcomplication of hyperthyroidism that maylead to cardiac failure. The manifestationof the patient rapidly develops triggered

by such conditions such as infection,especially pulmonary infection, sepsis,trauma, sever stress, abrupt thyroidmedication withdrawal or overuse and

diabetes mellitus.



ASSESSMENT FINDINGS • fever usually above 100oF• marked tachycardia with arrhytmias

• agitation and anxiety• hot, flushed skin• systolic hypertension• abdominal pain

• nausea and vomiting• profuse diaphoresis• diarrhea• dehydration

• As the thyroid storm progresses, the patient mayenter a stupor, then a coma. Hypertension andvascular collapse may follow.



INTERVENTIONS • Drug therapy• high doses of anti-thyroid drugs –

Propylthiouracil, Methimazole, iodine• Glucocorticorticoids• Temperature control with hyperthermia blanket• Replacement of fluid volumeNURSING DIAGNOSES • Altered Body Temperature, Increased related

to the disease process • Potential For Alteration In Nutrition, Less

Than The Body Requirements related toincreased metabolic body rate

• Ineffective Copping related to excessive anxiety• Potential For Decreased Cardiac Output

related to hypermetabolic responses • Potential For Alterations In Bowel

Elimination related to diarrhea



NURSING INTERVENTIONS

• Maintain a patent airway and adequatebreathing

• Maintain IV fluid rate as ordered

• Administer medications as ordered

• Reduce fever with cooling blankets andnonslicylate antipyretics

• Continuous assessment and monitoring for

changes in the patient’s condition.



DIABETIC KETOACIDOSIS t



DIABETIC KETOACIDOSIS – an acutemetabolic emergency characterized bysignificant hyperglycemia and ketonemiawhich result directly from an absolute or

relative insulin lack, leading to severedehydration (from osmotic diuretic),metabolic acidosis (from hyperketonemia),electrolyte depletion (from osmoticdiuresis), and hyperosmolarity (from

hyperglycemia and dehydration).Assessment Findings• Early symptoms include:• polyuria, polydipsia, fatigue, malaise,

drowsiness• anorexia, headache, abdominal pain• muscle cramps, nausea, vomiting,

constipation



Late symptoms include• Kussmaul breathing deep, rapid respiration

characteristic of diabetic or other causes of acidosis.Syn: Kussmaul-Kien respiration.

• Sweetish odor of the breath (due toketonemia)

• Hypertension and weak, thready pulse• Stupor and coma

Intervention

• Insulin• Fluid and electrolyte replacement• Treat acidosis if necessary



Nursing Diagnosis• Potential for fluid volume deficit related

to polyuria, dehydration• Altered nutrition, less than the bodyrequirements related to nausea, vomiting

• Potential for electrolyte imbalance related

to polyuriaNursing Interventions• Monitor fluid and electrolyte balance –

MIO, Monitor laboratory studies

• Continuous assessment for changes inthe patient’s status

• Administer medications





ASSESSMENT FINDINGS • changes in the ECG waveforms

• unconsciousness – in V-tach, Asystole TREATMENT• Heart Block • First Degree – No treatment

• Second Degree – atropine, pacemaker,Isuprel

• Third Degree – Pacemaker, Maintain onatropine and Isuprel

• (ISOPROTERENOL) while awaiting

pacemaker insertion



• Ventricular Tacycardia –

Cardioversion, Lidocaine • Ventricular Fibrillation –

Defibrillation; If unsuccessful with

defibrillation, Epinephrine 1 mg. • Ventricular Asystole – Initiate CPR,

Epinephrine, Atropine or

Isopreterenol, Pacemaker insertion



NURSING DIAGNOSIS • Alteration in cardiac output, less, related to

arrythmias

• Alteration is in tissue perfusion related to areduced cardiac output• Fear or Anxiety related to possible death• Knowledge deficits related t inadequate

information regarding treatment options, disease

processNURSING INTERVENTION • Asses for rhythm disturbances• Watch for signs of hypoperfusion (such as

hypotension, diminished urine output) for patients

with abnormally rapid, slow or irregular pulse• Look for indications of predisposing factors,

such as signs of drug toxicity, especiallydigoxin – report to the doctor and witholdnext dose





ACUTE MYOCARDIAL INFARCTIONASSESSMENT FINDINGS

• Severe, persistent chest pain unrelievedby rest or NTG• Changes in vital signs such as the pulse

may become rapid, iregular or slow, BP maybe normal , elevated or lowered, Elevatedtemperature during the first 24 to 48hours due to tissue necrosis

• Others symptoms such as feeling ofan impending doom, nausea and

vomiting, shortness of breath, coolextremities, perspiration, anxiety,palpable precordial pulse, muffledheart sounds



INTERVENTIONS • Morphine or Meridine for pain and sedation• Strict bedrest with bedside commode• Oxygen administration at a modest flow rate for

24 to 48 hours• Thrombolytic therapy up to 6 hours after

infarction

• PCTA• Drug Therapy• NTG• Lidocaine or other antiarrythmic drugs

• Dobutamine (inotropic drug to treat reducedmyocardial contractility)

• Betablockers to prevent furtherreinfarction

• Atropine – to treat bradycardia



NURSINGDIAGNOSES • Alteration In Cardiac Output related to

problems with the preload, afterload orcontractility; structural problems such asaneurysms

• Acute Pain related to disease process /ischemia

• Anxiety related to fear death, acutenessof the illness • Alteration In Cardiac Tissue Perfusion

related to a decreased cardiac output

• Potential for injury related tomyocardial ischemia and developmentof complications such as cardiogenicshock, arrhythmias



NURSING INTERVENTIONS • Prevent, detect and treat complications –

continuous ECG monitoring

• Assess pain, administer analgesics asordered

• Administer oxygen• Check vital signs, assess heart sounds

• Start ECG for new episode of chest pain• Control anxiety, provide emotional rest and

sleep by sedation• Bedrest – on proper positioning – for 24

hours until hemodynamically stable thenprogress activity



• Prevent venous stasis – leg exercises, TEDhose

• Elimination without strain – stoolsofteners, bedside commode

• Appropriate diet – Sodium and fluid

restriction, Fat controlled diet – I and O• Organize patient care and activities to

maximize periods of uninterrupted rest

• Begin rehabilitation while in CCU





• PREMATURITY – the termination of

pregnancy in the period fromapproximately the twenty eighthweek to the end of the 37th week of

gestation. Approximately 10% of alllive births are premature.

•Weight – often indicative of

prematurity and physiologicimmaturity.



A Premature Infant is one who weighs2500 Gms (5 lbs. 8oz.) or less at

birth ; his length from the crown to theheel is likely to be close to 18.5 inches(47cm). His behavior shows immaturity– lacking in normal reflexes and in ageneral ability to carry on vitalfunctions.• The incidence of prematurity ishighest among the low

socioeconomic status, andaccounts for the highestmortality rate among infants inthe first year of life.



• FACTORS ASSOCIATED WITH PREMATURITY multiple births premature separation of the placenta

maternal diseases such as infectious diseases,cardiac diseases, diabetes mellitus

fetal anomalies toxemia of pregnancy

placenta previa premature rupture of the membranes drug abuse chronic poor nutrition

IUD in the gravid uterus

• PREVENTION OF PREMATURITY – Adequate prenatal care for all

prospective mothers



PHYSICAL CHARACTERSITICS of PrematureInfants

• small and limp

• Skin – wrinkled and red, excess lanugo and littleor no vernix caseosa; very thin, capillaries visible• Head – relatively large with prominent eyes, soft

ears, and receding chin• Thorax – less firm and small

• Abdomen – relatively large and protrudes; thegenitalia are small – undescended testes in males,undeveloped labia minora in females

• Extremities – thin and small muscles; fingernailsand toenails are abnormally soft and short

• Subcutaneous tissue is deficient, his face giveshim an old man appearance• Normal reflexes such as sucking, swallowing

and gag reflexes are absent• Poor ear cartilage



PHYSIOLOGIC HANDICAPS OF APREMATURE INFANT

• Poor Control of Body Temperature – due to– an Immature nervous system, thus the

heat regulating is also immature– subcutaneous tissue is deficient, thus

lacks the insulation provided by such

– has poor muscular development thus heis inactive

– very slow metabolic rate



• Difficulty in respiration – due to animmature lungs

• Cyanosis– may be due to

– an increased ICP as a result ofbirth trauma

– obstruction of the respiratorytract by mucous secretions

– poorly developed lungs (immature)

– abdomen is relatively large andappear distended, thus mayinterfere with the movement of

the diaphragm



• Apnea – may result from– excessive analgesics or anesthetics given to

the mothers during labor and delivery

– general immaturity of the nervous system andthe respiratory tract

• Inability to Handle InfectionsAdequately

– has a poorly developed immune system andresponse• Tendency to Hemorrhage and Anemia –

may be due to– fragile blood vessels

– lacking in the normal supply of Vitamin K– RBCs are easily destroyed– tendency to loss blood more because he lack

iron and the other hematogenous factors



• Tendency for rickets to develop – lacks the ability to absorb fat-soluble vitamins

(Vit. A, D, E, K) from his feeding due to animmature GI tract

– lacks the Calcium, Phosphorus and Vitamin Dwhich is stored in the body of a full term infant

• Disturbance in nutrition – due to– a poor sucking and swallowing reflexes

– an immature GI tract

• Impairment of the Renal Function – due to– incomplete development of the kidney



CARE AND MANAGEMENT OFPREMATURE INFANTS

• Immedately After Birth Warmth

Place infant in an incubator provided withnecessary facilities for increasing

environmental oxygen and humidity Initiation Of Respiration

• Respiration should be cleared by suctioningmucous from the airway very gently

• Position the infant with head down fornatural drainage of position

• Administer artificial respiration with amechanical devise (resuscitator), if the

infant is hypoxic



Oxygen Administration – Should be given if respiration are not

established in the first few seconds and theinfants become cyanotic

Medications Commonly Used in treatingunusual conditions in the premature

– Epinephrine – Cardiac stimulant given IM– Caffeine sodium benzoate – given IM as

respiratory stimulant

– Vitamins K – given IM to reduce bleedingtendencies



Within The Nursery • Environment

– The nursery is isolated from all other unitsto minimize traffic and ensure protectionfrom infection

• Minimal Handling

– Lessens the danger of infection– Conserves the infant’s strength

• Maintenance Of Body Temperature – The infant is placed in an incubator in a warm

nursery to provide the requiredenvironmental heat in order to maintain theinfant’s body temperature



• Maintenance Of Respirations

– Vaporizers are used to provide highhumidity

– Positioning the infant on his side to getthe maximum amount of air into the

lungs – change his position every 3-4hours

– Administer oxygen if necessary –

concentration should not exceed 40%



• Nutrition – Formulas should be high in protein, low in

fat and of average carbohydrate content

– The premature infant has a small gastriccapacity but a great need for calories; thus hecan tolerate small frequent feedings

– Methods of feeding include – gavage feeding for small prematures without good sucking orswallowing reflexes; Dropper or nipple feeding for vigorous premature infants with a goodsucking and swallowing reflex; or

gastrostomies , if indicated.– Allow the infant to rest prior to feeding – he

easily tires from procedures and will eatbetter if rested.



• Medications Necessary For Growth and development

– Vitamin C 50 mg– Vitamin D 1000 I.U. – given within 2weeks

– Iron – by about six weeks when the

infant is 1.5 to 2 times birth weight • Prevention Of Infection

– Sterile feeding equipment to prevent GIinfection.

– Scrupulous hand washing by all personnelhandling the infant and entering thenursery.



• Such infant must have his own equipment,supplies used should be sterile as much as

possible.• Use gown and mask technique as

prescribed by hospital protocol.• Minimize the number of persons who come

in contact with the premature infant.• Nurses or other health personnel who

come in contact with these infants shouldbe free of any type of infection.

• There should be no dry dusting orsweeping in the nursery.

SPECIAL HEALTH PROBLEMS OF THE



SPECIAL HEALTH PROBLEMS OF THEPREMATURE INFANT

Retrolental Fibroplasia – the abnormal

replacement of the sensory retina byfibrous tissue and blood vessels occurringmainly in premature infants who aresubjected to a high oxygen environment.

• Oxygen given beyond the point of infantneed will cause the retinal arteries toconstrict resulting to anoxia. The retinadetach from the surface of posteriorchambers and a fibrous mass forms,

resulting in an ability to receive visualstimulation.• This is the chief cause of blindness

among infants under 1500 gm of birthweight and of gestational age of sixto seven months.



Respiratory Conditions Anoxia Of The Newborn – a condition

wherein the infant’s vital organs, especially

the brain receives less oxygen than theyneed for optimum functioning – due to anycause which limit the oxygen supplied byway of the maternal and fetal circulationfrom reaching the brain of the fetus.

• Symptoms • yellow, meconium-stained amniotic fluid

and yellowish vernix caseosa• pallor or cyanosis• lack of muscle tone• variable heart beat



Interventions

• Respiratory resuscitation• Oxygen administration

• Administer Nalorphine Hydrochloride(Nalline) a powerful emergencyrespiratory stimulant when the causeof dpression is a narcotic

• CPR



• Respiratory Distress Syndrome – alsoknown as Infant Respiratory DistressSyndrome (IRDS), previously called

Hyaline Membrane Disease– Results from a deficiency of the alveolar

surfactant as caused by an immaturesurfactant production – the synthesis of

surfactant in the utero takes place for lungmaturation to be complete at about 35 weeksgestation. Healthy full term infants producemore surfactant that they actually need – theexcess spills into the amniotic fluid where it

is lost or discarded when the amniotic sacruptures during delivery.

• Symptoms



Symptoms • cyanosis

• tachypnea

• retractions

• nasal flaring and see-saw respiration

• diminished breath sounds

• hypotension

• Interventions – Administration of oxygen

– Administration of syntheticsurfactant – via tracheal drip topremature infants

Other Complications



p• Hypoglacemia – the infant’s serum sugar

levels are less than 25 mg/100 ml dil – occur as a result of the reduced glycogenstorage of the premature infant at birthand his limited carbohydrate tolerance

• Symptoms – jitterness– lethargy– tachypnea or apnea– cyanosis– convulsions

– high pitched, week cry– pallor– sweating

• Intervention – Increase blood sugar intake by oral feeding or IV

slowly



NURSING DIAGNOSES AND SPECIFIC



NURSING DIAGNOSES AND SPECIFICNURSING INTERVENTIONS for thepremature infants and family

• Potential For Impaired Gas Exchangerelated to lack of sufficient surfactant

• Potential for Fluid Volume Deficit relatedto insensible water loss and inadequatefluid intake

• Alteration in nutrition – less than the bodyrequirements, related to actual intake lessthan the caloric requirements

• High Risk for Infection related toImmature Immune System

• Parental Knowledge Deficit related to

the care of the preterm infants





POSTMATURITY - The postmatureinfant is one who remains in the uterusfrom one to three weeks or more after

the expected date of delivery – beyond 42weeks or 300 days of gestation – and whomay show signs of weight loss withplacental insufficiency.

• About 5% of the newborn infants are bornpostmature. These infants may experiencethe effects placental insufficiency as aresult of aging, intrauterine malnutrition andhypoxia.

• Normally, before the termination of thepregnancy, at the point when birth shouldhave occurred, the placental function beginsto diminish, resulting in impaired oxygen and

inadequate nutrient transfer to the fetus.

PHYSICAL CHARACTERISTICS OF



PHYSICAL CHARACTERISTICS OFPREMATURE INFANTS

• reduced or absent vernix caseosa and

lanugo• abundant scalp hair• reduced subcutaneous tissue – loose skin

especially on the buttocks and thighs

• cracked, thin skin – wrinkled maceratedskin• greenish-yellow staining of the skin, nail

and cord-indicating fetal distress

• having an alert, wide-eyed look just like a 2to 3 week old infant, following delivery

CLINICAL PROBLEMS OF POSTTERM



CLINICAL PROBLEMS OF POSTTERMINFANTS

• Hypoxia

• Meconium aspiration• Perinatal asphyxia• Polycythemia• Thermal regulation problems

• Pulmonary problems such as pneumonia,pneumothorax

MANAGEMENT OF POSTMATURITY – concerned with the termination of

pregnancy either by – • Induction of labor• Ceasarean section



NURSING DIAGNOSES and NURSINGINTERVENTIONS

• Impaired Gas Exchange related to Hypoxiaor Meconium Aspiration secondary toplacental insufficiency

• Alteration In Nutrition, Less Than The

Body Requirement related to an increasedcaloric requirement• Parental Knowledge Deficit Related to the

care of their postterm infants

• Potential for Injury related to problemsassociated with the complications commonamong post term infants.

GRAVIDA CARDIAC PATIENT IN LABOR



GRAVIDA-CARDIAC PATIENT IN LABOR – The diagnosis of cardiac disease is not anindication for the early induction of labor.Clients are usually allowed to go intospontaneous labor. However, aninterdisciplinary team effort is needed to

appropriately manage the pregnant womanwith cardiac disease – MANAGEMENT OF GRAVIDA-CARDIAC

PATIENTS IN LABOR

• Hospitalization for a short period prior tothe expected onset of labor is occasionallyrecommended.



– Relief of Discofort and Anxiety duringthe labor – effective intrapartum painrelief may reduce cardiac workload byas much as 20%

• Systematic analgesics combined withsedatives – may be administered early in thefirst stage of labor

• Caudal or epidural anesthesia – may beinitiated, as the labor will progress



• Maintain the patient on a Leftside-lying position – to improve

cardiac circulation and maximizeoxygenation

• Administer oxygen – if pulmonary

complications arise• Perform continuous fetal monitoring

• Attach the patient to continuous

ECG monitoring and performcontinuos hemodynamic monitoringas indicated.



• Administer medications as needed

– Prophylaxis antibiotics – for patientswho will undergo ceasarean section

– For patients with prosthetic valves andreceiving anticoagulant therapy (life-

long treatment) – hold before deliveryand resume 6 – 12 hours after delivery

C t ll d V i l D li



Controlled Vaginal Delivery – preferred CS

• Delivery is done is the lateralposition of in a supine position withthe client tilted to the left – todecrease the risk of hypoventilation

• Use of high stirrups iscontraindicated or inappropriate.

• Forceps or vacuum extractor –

commonly applied during the secondstage of labor to avoid the stress ofincreased abdominal pressurecreated by the maternal pushing

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Emergency 3

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