Chapter 14

Clinical observation

and Emergency Treatment for critically ill patients

Emergency

Section Ⅰ clinical observation Section Ⅱ Emergency Treatment for

critically ill patients Organization and management of resuscitation Management of resuscitation equipments Resuscitation skills commonly used Supportive care for critically ill patients

Critically ill patients

Critically ill patients are those who are in serious condition, and may possibly have the danger of life-threatening at any moment.

The basis to successful resuscitation is timely, comprehensive and accurate observation and recording of the patients’ condition.

The key to successful resuscitation is to apply all the resuscitation techniques skillfully.

The guarantee to successful resuscitation is the organization and management of rescuing work.

Section Ⅰ clinical observation

The purposes of clinical observation The requirements of nursing staff The methods of clinical observation Contents of clinical observation

The purposes of clinical observation

Providing the scientific basis to the diagnosis, treatment and nursing of diseases.

Forecasting the trend and outcome of diseases. Knowing the effectiveness of treatment and

medication effects on patients timely. Finding the signals of the changes of critically ill

patients’ conditions, in case of the aggravation of diseases.

the requirements of nursing staff

rich and profound medical knowledge great responsibility acute observational ability

the principles of being frequent in five aspects.

frequent inspectionfrequent observationfrequent enquiryfrequent consideration frequent record

the methods of clinical observation inspection auscultation palpation percussion smelling

Besides the commonly used five methods above, health care givers require effective communication.

Contents of clinical observation

Observation of general condition Observation of vital signs Observation of consciousness Observation of pupils Observation of psychology Observation of diagnostic studies or drug treatment Observation of other aspects

Observation of general condition

Development and body figure Diet and nutritional status Facial features and expression Position Posture and gait Skin and mucous membrane

Observation of vital signs

Body temperature Pulse Respiration Blood pressure

Observation of consciousness

Consciousness is the comprehensive reflection

of how cerebrum reacts to the environment.

Disturbance of consciousness

Somnolence Confusion Stupor Coma Light coma

Deep coma

Glasgow Coma Scale, GCS

The scale comprises three tests: eyes opening (4 grades) verbal response (5 grades) and motor responses (6 grades)

The highest possible GCS (the sum) is 15 (fully awake person), while the lowest is 3 (deep coma or death).

If the score is less than 7 and more than 3, it’s light coma.

Best eye response

There are 4 grades starting with the most severe:

No eye opening.......................................1 Eye opening in response to pain...........2 Eye opening to speech ..........................3 Eye opening spontaneously.................4

Best verbal response There are 5 grades starting with the most severe:

No verbal response .................................1 Incomprehensible sounds ......................2 Inappropriate words ..............................3 Confused conversation ...........................4 Oriented ..................................................5

Best motor response

There are 6 grades starting with the most severe:

No motor response..................................1 Extension to pain ...................................2 Abnormal flexion to pain ......................3 Flexion/Withdrawal to pain ..................4 Localizing response to pain ...................5 Obeying command .................................6

Observation of pupils

The shape, size and symmetry of pupils Light reaction

Shrinking: the diameter of a pupil is smaller than 2mm.

Bilateral pupil diminished may be seen when there are poisoning conditions of organophosphorous insecticides( 有机磷农药 ), chlorpromazine( 氯丙嗪 ) and morphine( 吗啡 ).

Unilateral pupil diminished may indicate the earlier stage of transtentorial hernia( 小脑幕裂孔疝 ).

Largening: the diameter of a pupil is bigger than 5mm, (mydriasis)

Bilateral pupil dilated commonly is seen with the state of intracranial hypertension( 颅内高压 ), craniocerebral injury ( 颅脑损伤 ), Belladonna poisoning ( 颠茄类药物中毒 ) and dying.

One side pupil dilated and fixed may indicate the occurrence of transtentorial hernia ( 小脑幕裂孔疝 ) which caused by same side intracranial hematoma ( 颅内血肿 ) or brain tumor.

Observation of diagnostic studies or drug treatment

Observation after diagnostic studies or treatment Observation of patients treated by special drugs: the effect the side effect the toxicity of medications

Section Ⅱ Emergency Treatment for critically ill patients

Closely knit organization Reasonable assignment Essential and perfect equipment Skilled medical workers Necessary emergency drugs

Organization and management of resuscitation

Resuscitation team

director head nurse

Formulate resuscitation plan

work out the nursing plan

cooperate with doctors to carry on the rescue

record verify

continue with the clinical observation after resuscitation and pass nursing report to the next shift nurses.

attend while doctors conduct the ward round, make consultations and discuss the cases of illness.

Management of resuscitation equipments

resuscitation room resuscitation bed resuscitation cart Emergency equipments

resuscitation cart

Emergency drugs Emengency sterile packages others

Emergency equipments

oxygen source suction apparatus electrical defibrillator pacemakers ECG (electrocardiograph) monitor Ambu-bag Respirator Automatic gastrolavage machine, etc.

Management of equipments and drugs in

resuscitation room

Strictly implement the “Five Fixed” system: fixed amount fixed places to arrange fixed staff in charge disinfecting at fixed time maintenance at fixed periods.

Resuscitation skills commonly used

Cardio-pulmonary Resuscitation (CPR) Gastric lavage

Sudden cardiac arrest， SCA

(Heart-lung resuscitation)

CPR is a combination of oral resuscitation that supplies oxygen to the lungs, and external cardiac massage (chest compression), which is intended to reestablish cardiac pump function and blood circulation.

when a cardiac arrest or respiratory arrest occurs,

a combined effort is made to restore or maintain

respiration and circulation, artificially.

oral resuscitation

chest compression

The cardinal signs of a cardiac arrest

unconsciousness absence of a carotid pulse apnea dilated pupils pale or cyanosed skin absence of heart sounds nil bleeding from wound

Basic Life Support (BLS)

compression

airway

breathing

Advanced life support(ALS)

Prolonged life support(PLS)

Purpose

To establish artificial circulation and respiration

To circulate oxygenation blood to the vital organs to prevent permanent tissue damage

Indications Cardiac arrest and/or respiratory arrest

ContraindicationsPresence of heart beat and breathingSevere injuries to thorax or heartSevere deformity of thorax and spine

Equipment chest compression board step bench blood-pressure meter Stethoscope Oral airway or face mask if available Ambu bag if available

Procedures--

Assess whether victim is unconscious:

shaking client's shoulders gently

shouting

Procedures--

If victim is not responsive,

activate Emergency medical

Services -EMS (call 120).

120

Procedures--

Place the client on hard surface Place the client in supine position Take away pillow under client's head and loosen

client's collar and belt

Procedures-- check the carotid pulse

Locate it by placing two fingers in the groove between the Adam’s apple and the muscle.

★If there is a pulse★If there is no pulse ＜ 10s

If there is a pulse

ventilate victim at rate of one breath every 5 seconds (10-12/min)

Recheck the carotid pulse every 2 minutes

If breathing resumes, observe carefully to verify

continued spontaneous respiration.

If there is no pulse, initiate chest compression

A person in bed must be moved to the floor,

or a cardiac board.

Locate the position for compression

Place the hands on the breastbone at the nipple line.

Keep fingers off chest wall

the heel of the hand

Place another hand on top of the hand

Extend arms and lock elbow. Maintain arms straight and

shoulders directly over victim’s sternum.

Press straight down on the sternum,

compressing the chest 5 cm.

Then release pressure, maintaining

contact with skin.

Give compressions at rate of 100 /min,

counting “one and two and,” etc, up to 30.

Procedure-- open airway

head-tilt, chin-lift method

a.Place palm of one hand on victim’s forehead.

b.Place fingers of another hand under victim’s chin.

c.Simultaneously push down on forehead and lift upward on chin.

Use care to avoid pressure on the soft tissue of the throat.

jaw thrust method —If head or neck trauma is suspected

grasp angles of victim's lower jaw and lift with both hands, displacing mandible forward.

If victim is not breathing,

administer artificial breathing

Mouth-to-mouth

Mouth-to-nose

Mouth-to-mouth/ nose

Mouth-to-mouth resuscitation

a. Pinch nostrils together.

b. take a deep breath and place mouth over the victim’s mouth, forming a tight seal.

c. Blow two full breathes into the client's mouth (each breath should last 1 second); allow the client to exhale between breathes by loosing the nose.

Mouth-to-nose resuscitation

Keep victim's head tilted with one hand on forehead.

Use another hand to lift jaw and close mouth.

Seal nurse's lips around victim's nose and blow.

Allow passive exhalation.

After 2 full ventilations,

reposition hands correctly,

give 30 compressions.

The ratio of compressions to breath is 30 to 2 for one or two rescuer.

After the 5 cycle CPR, check carotid pulse and resume CPR if absent.

Recheck pulse every few minutes, but do not interrupt CPR for more than 10s.

Pulse should also be checked if signs of recovery such as movement, swallowing, or returning facial color occur.

If pulse is present, continue ventilations every 5s without compressions if the client does not resume breathing.

Continue CPR until heartbeat and breathing are

restored, EMS arrives, or victim is pronounced dead

by a physician.

If heartbeat and breathing resume, continue to

observe and arrange for transport of victim to

hospital.

Gastric lavage is a medical approach for therapeutic irrigation of stomach by inserting a gastrolavage tube to stomach via mouth or nasal cavity, through which certain quantity of irrigating solution is pumped into stomach by gravity, siphonage, and negative pressure suction.

Purpose

Detoxification: Clear the stomach contents or other harmful substance.

Alleviate the edema of stomach mucosa: Wash out food in stomach; Alleviate stimulation, edema and inflammation of stomach mucosa.

preparations needed before some operation or diagnostic studies.

Acute toxicosis, especially within 6h after it

Contraindications

Clients who have ingested erosive (alkali or acid) substance.

upper alimentary tract hemorrhage( 上消化道出血 ); upper alimentary tract ulcer; gastric perforation( 胃穿孔 ); cancer of stomach; Cirrhosis of liver( 肝硬化 ) with esophageal and gast

ric varication( 食管胃底静脉曲张 ); thoracic aortic aneurysm ( 胸主动脉瘤 ).

Common antidotes and contraindicated medications

Induction of vomiting with 3% hydrogen peroxide

solution first, then irrigation with 1:15000-1:20000

Potassium Permanganate

Irrigating SolutionToxicantContraindicated

Medications

Acid

substance Milk of magnesia, egg-water, milk Strong acid medication

Alkaline

substance5% acetic acid, egg-water, milk Strong alkaline medication

Cyanide

Gastrolavage with 2%-4% baking soda,

l% saline, 1:15000-1:20000 Potassium Permanganate

Toxicant Irrigating SolutionContraindicated

Medications

Dichlorvos

1605 1059 4049

Gastrolavage with 2%-4% baking soda Potassium Permanganate

DipterexGastrolavage with 1% saline or water, 1:15000-1:20000 Potassium Permanganate

Alkaline medication

DDT 666

Gastrolavage with warm water or. normal saline, 50% magnesium sulfate catharsis

Oil cathartic

Phenols saponated cresol

Gastrolavage with warm water and vegetable oil until no phenols smell, then ask the client to drink milk, or egg white to protect stomach mucosa

Phenol

Toxicant Irrigating SolutionContraindicated

Medications

Gastrolavage with 1:15000-1:20000Potassium Permanganate

Barbital Gastrolavage with 1:15000-1:20000Potassium Permanganate, catharsis with Sodium sulfate

IsoniazidGastrolavage with 1:15000-1:20000Potassium Permanganate, catharsis with Sodium sulfate

Phosphatic zinc

Gastrolavage with 1:15000-1:20000Potassium Permanganate, or 0.1% copper sulphate

Egg, milk, fat and others

The preparation before operation

Assessment Assess the client and explain to him or her the

purpose and method of Gastrolavage and

precautions taken during operation.

Equipment

Tray Filler gastrolavage tube, forceps, and gauze Toilet paper Adhesive tape Paraffin oil Kidney tray Sterile cotton swab Plastic apron Measuring cup Thermometer Tongue blade Mouth-gag Irrigating solution (25 -38 )℃ ℃ Buckets (one for filling gastrolavage irrigation, one for filling

waste water) Test container or test tube

Equipment for gastrolavage with electric

suction apparatus Electric suction apparatus Gastrolavage tube (without filler) IV pole, bottle, and tube Y-tube Clamp

Equipment for lavage with automatic

gastrolavage machine Automatic gastrolavage machine Gastrolavage tube (without filler)

Gastrolavage

Oral emetic method

Gastric tube method

-filler irrigating gastrolavage

-electric suction apparatus gastrolavage

-automatic gastrolavage machine

Procedures ----Oral emetic method

--applied to clients with consciousness who can cooperate with nurses.

Ask the client to drink a lot of irrigating solution, and induce vomiting.

Irrigating repeatedly until the returns from stomach are clear and without smell.

400-500ml fluid once

Gastric tube-filler irrigating gastrolavage

inserting the filler gastric tube

Lower the filler below the level of stomach, crush the rubber ball and aspirate stomach contents

The tube is inserted into 55-60cm

siphonage

1 Raise the filler 30 ～ 50cm over the client's head

2 pour 300-500ml irrigating solution into the filler

3 When there are few solutions in the filler, lower the filler below the level of stomach, and inverses filler in the bucket rapidly.

Repeat irrigating until the returns from stomach are clear and without smell

Gastic tube- electric suction apparatus gastrolavage

The negative pressure is within the range of about 13.3kPa.

Y-tubeY-tube

Gastic tube-electric suction apparatus gastrolavage

transfusion Bottle ( 300-500ml )

IV pole

transfusion tube

gastrolavage tube

irrigating tube

waste tube

Gastric tube-automatic gastrolavage machine

Pour the irrigating solution into the bucket, and connect three rubber tubes respectively to the medication tube, gastric tube and waste tube. Put the other end of medication tube in the irrigating solution bucket, and put the other end of waste tube in the empty bucket. Attach the other end of gastric tube to client's gastric tube. Adjust the rate of medicine flow. irrigating

solution

The end of gastric tube

Supportive care for critically ill patients Strengthen the monitoring of patients’ condition Maintain a patent airway strengthen the clinical basic care Maintain good hygiene of a patient Eyes care Oral care Skin care Keep excretory system functions Maintain the function of limbs Pay attention to patients’ safety Keep the drainage tube unobstructed emphasize psychological care for critically ill patients