EMERGENCY ASSESSMENT

Its better to know first aid and not need it than to need it and not know it
What is First Aid?
First aid is one of those things you need to know- but never want to use
It is the immediate care given to an injured or suddenly ill person.
It furnishes temporary assistance until the victim receives competent medical care.
Properly applied it may mean the difference between life and death
Legal Considerations
Consent- before giving first aid, a first aider must have the victims consent.
1. Expressed consent- must be obtained from every conscious, mentally competent person of legal age.
2. Implied consent- involves an unresponsive victim in a life-threatening condition. It is assumed that an unresponsive victim would consent to lifethreatening situation
Legal considerations
Abandonment- means leaving a victim after starting to give help without ensuring someone else will continue the care at the same level or higher.
Negligence- means not following accepted standards of care and causing injury to the victim. It involves
1. Having a duty to act- ex. When employment requires it- law enforcement officers, life guards. When pre-existing responsibility exist- ex. A parent for
a child
2. Breach of Duty- ex. Act of omission,Act of commision
3. Injury and Damages inflicted- Physical, mental, loss of income, medical expenses
Legal considerations
Good Samaritan Laws- In most emergencies, you are not legally required to give first aid.
1. It grants you immunity against lawsuits.
Applies only when:
a. Acting during emergency
b. Acting in good faith
c. Acting without compensation
d. Not guilty of malicious misconduct or gross negligence towards the victim
Action at an Emergency
Recognize the emergency- usually a persons appearance or behavior or the surroundings suggest an emergency.
Scene survey- 1. hazards that could be dangerous to you, the victim and the bystanders; 3. the number of victims
Decide to help- the most important time to make the decision to help is before you ever encounter an emergency.
Call EMS, if needed- Dont delay calling for an ambulance
Assess the victim- you must decide if life-threatening conditions exist and what kind of help a victim needs immediately.
Provide care- the most critical life support measures are effective only if started immediately
Seek medical attention- when a serious situation occurs call EMS
Disease precaution
Blood borne disease- HBV, HBC, HIV
Airborne disease- TB
COPING WITH EMERGENCIES
1. Wear PPE
2. Use universal precautions and body isolation techniques
Finding Out Whats Wrong
Immediate Threats to Life
A: AIRWAY- must be open for breathing.
B: BREATHING- 12 to 20 normal for adults. Look, listen and Feel
C: CIRCULATION- check signs of circulation( breathing, coughing, movement, and normal skin condition)
Physical Exam and SAMPLE history
Note the victims signs and symptoms
SIGNS- victims conditions you can see, feel hear or smell
SYMPTOMS- things the victim feels and is able to describe. Chief complain
Physical Exam
Check for victims head, neck, chest, abdomen, pelvis and extremities
Look for D-O-T-S
D-eformities occur when bones are broken, causing an abnormal shape
O-pen wounds break the skin
T-enderness is sensitive to touch
S-welling is the bodys response to injury that makes the area larger than usual
Things to look for and feel during the exam
Head- DOTS, leakage of blood or fluid from the nose or ears
Eyes- PERRLA
Neck- DOTS
Chest- DOTS, pain
Abdomen- DOTS, rigidity and tenderness on all 4 quadrants
Pelvis-DOTS, gently squeezed inward and press outward
Things to look for and feel during the exam
Extremities- DOTS and CSM(Circulation, Sensation and Movement)
SAMPLE history

S= Symptoms
Whats wrong? (Chief complain)
A= Allergies
are you allergic to anything?
M= Medications
Are you taking any medication?,What are they for?
P= Past medical history
Have you had this problem before? Do you have other medicl problems?
L= Last oral intake
when did you last eat or drink anything? What was it?
E= Events leading up to the illness or injury
How did you get hurt? What led to this problem?
Emergency and critical care
Basic life support (BLS)
A means of providing oxygen to the brain, heart and other organs until help arrives
Also known as CARDIOPULMONARY RESUSCITATION
An adult is a person above age 8
A child is any person age 1 to 8 years old
An infant is anyone under 1 year
The BLS follows the A-B-C principle

A= airway

B= breathing

C= circulation

Causes of cardiac arrest

Respiratory arrest
Direct injury
Drug overdose
Cardiac arrhythmias

ADULT

STEPS in CPR: First STEP!!!

ASSESSMENT: determine Unresponsiveness
Assess for 5-10 seconds
Shake the victims shoulder and ask: are you okay

STEPS in CPR: Second Step

Survey the area

STEPS in CPR: Third Step

Call for HELP
Activate emergency medical system
Note: for child and infant this is done LAST

STEPS in CPR: Fourth step

Place Victim in Supine position on a flat firm surface
Log roll the patient when moving

STEPS in CPR: Fifth step

OPEN the airway
Head tilt-Chin Lift method
Jaw thrust maneuver if neck injury is suspected

STEPS in CPR: Sixth step

Assess BREATHING
Place ear over the nose and mouth
Look for chest movement
Perform for 3-5 SECONDS

STEPS in CPR: Seventh step

Assess BREATHING
If breathing: place on side if no neck injury; DO NOT move if with neck injury
If NOT BREATHING: deliver INITIALLY 2 rescue breath via mouth to mouth
Then deliver 10-12 breaths/minute

STEPS in CPR: Eight step

Assess CIRCULATION
Check for the carotid pulse on the side close to you for 5-10 SECONDS
If with (+) pulse ; continue giving 10-12 breaths/minute

STEPS in CPR: Ninth step

Assess CIRCULATION
If withOUT pulse: START Chest Compression
Correct hand placement: LOWER HALF of sternum one hand over the other with fingers interlacing

 Depress: 1 to 2 INCHES
80-100 compressions/min

STEPS in CPR: Seventh step

Assess CIRCULATION
If withOUT pulse: START Chest Compression
ONE-rescuer: 15 chest: 2 breaths
TWO-rescuer: 5 chest: 1 breath
DO FOUR cycles and re-assess for pulse

Basic life support (BLS)

CHILD
1-8 years old
AIRWAY: assess unresponsiveness and keep airway patent by HTCL or JT
BREATHING: assess for airflow and chest movement
If breathing: maintain patent airway
If NOT breathing : deliver 2 rescue breaths by mouth to mouth
DELIVER 20 breaths/minute
1-8 years old
CIRCULATION: assess the carotid pulse
If with pulse: continue to deliver 15-20 breaths/minute
If WITHOUT pulse: start chest compression
Correct hand placement: lower half of sternum using heel of ONE HAND
DELIVER: 1 to 1 inches
80- 100 chest compressions/min
5:1 (do 20 cycles EMS)
Less than 1
Determine unresponsiveness
AIRWAY: Place head of infant in NEUTRAL position
BREATHING: assess for rise-fall of chest and airflow
If breathing: maintain patent airway
If NOT breathing: initiate 2 rescue breathing via mouth to mouth and nose
DELIVER 20 breaths/min SLOWLY
Less than 1
CIRCULATION: assess for pulse: The BRACHIAL pulse is utilized!!
If with pulse: continue to deliver 20 breaths/min
If WITHOUT pulse, start chest compression
Correct hand placement: just below the nipple line in the sternum using 2-3 fingers of one hand!!
DELIVER: to 1 inch depth
100 chest com/min
5:1 ratio (do 20 cycles EMS)
Basic life support (BLS)
INFANT
Less than 1
CIRCULATION: assess for pulse: The BRACHIAL pulse is utilized!!
If with pulse: continue to deliver 20 breaths/min
If WITHOUT pulse, start chest compression
Correct hand placement: just below the nipple line in the sternum using 2-3 fingers of one hand!!
DELIVER: to 1 inch depth
100 chest com/min
5:1 ratio (do 20 cycles EMS)
AIRWAY Obstruction
Incomplete
Crowing sound is heard encourage to cough

Complete
Clutching of the neck
Ask: Are you choking?
Perform Heimlichs
Complete
If patient becomes unconscious:
Place supine on flat surface
Perform tongue-jaw lift maneuver
FINGERSWEEP to remove object
Open airway and attempt ventilation
Perform Heimlich while supine
Reattempt ventilation
SEQUENCE: TJL finger-sweep rescue breaths Heimlichs TJL
Pediatric considerations:
CHILD: NEVER DO Blind Finger sweep
Pediatric considerations:
INFANT: never DO blind finger-sweep
Give five back blows in the interscapular area and turn the infant with head lower than trunk then deliver chest thrust below the nipple line
Obstetric considerations:
Hand is placed over the middle part of sternum: backward chest thrust


Shock

If unconscious: place pillow below the RIGHT abdomen to displace uterus

An abnormal physiologic state where an imbalance exists between the amount of circulating blood volume and the size of the vascular bed.

Pathophysiology of Shock
1. Cellular effects of shock
In the absence of oxygen, the cell will undergo Anaerobic metabolism to produce energy source and with it comes numerous by-products like lactic
acid
The cell will swell due to the influx of Na and H20, mitochondria will be damaged, lysosomal enzymes will be liberated, and then cellular death
ensues.
2. Organ System Responses
When the patient encounters precipitating causes of shock, the circulatory function diminishes there is decreased cardiac output Hypotension
and decreased tissue perfusion will result
Shock Stages
There are three stages of shock
Compensatory stage
Progressive stage
Irreversible stage

THE COMPENSATORY STAGE OF SHOCK

In this stage, the patients blood pressure is within normal limits.
Patients blood is shunted from the kidney, skin and GIT to the vital organs- brain, liver and muscles
Manifestations of cold clammy skin, oliguria and hypoactive bowel sounds can be assessed.
Medical management includes IVF and medication
Nursing management includes monitoring of tissue perfusion & vital signs, reduction of anxiety, administering IVF/ordered medications and
promotion of safety
THE PROGRESSIVE STAGE OF SHOCK
In this stage, the mechanisms that regulate blood pressure can no longer compensate and the mean arterial pressure falls.
The overworked heart becomes dysfunctional. Heart rate becomes very rapid (as high as 150 bpm)
Blood flow to the brain becomes impaired, the mental status deteriorates due to decreased cerebral perfusion and hypoxia.
Laboratory findings will reveal increased BUN and Creatinine. Urinary output decreases to below 30 mL/hour.
Decreased blood flow to the liver impairing the hepatic functions. Toxic wastes are not metabolized efficiently, resulting to accumulation of
ammonia, bilirubin and lactic acids.
The reduced blood flow to the GIT causes stress ulcers and increased risk for GI bleeding.
Hypotension, sluggish blood flow, metabolic acidosis (due to accumulation of lactic acid), and generalized hypoxemia can interfere with normal
blood function.
THE IRREVERSIBLE STAGE OF SHOCK
This stage represents the end point where there is severe organ damage that patients do not respond anymore to treatment. Survival is almost
impossible to maintain.
Despite treatment, the BP remains low, anaerobic metabolisms continues and multiple organ failure results.
Medical management is the use of life supporting drugs like epinephrine and investigational medications.
Assessment of Shock
Assessment Findings
Skin
: Cool, pale, moist in hypovolemic and cardiogenic shock
: Warm, dry, pink in septic and neurogenic shock
Pulse
Tachycardia, due to increased sympathetic stimulation
Weak and thready
Blood pressure
1. Early stages: may be normal due to compensatory mechanisms
2. Later stages: systolic and diastolic blood pressure drops.
Assessment Findings
Respirations: rapid and shallow, due to tissue anoxia and excessive amounts of CO (from metabolic Acidosis)
Level of consciousness: restlessness and apprehension, progressing to coma
Urinary output: decreases due to impaired renal perfusion
Temperature: decreases in severe shock (except septic shock).
Management of Shock
Nursing Interventions
Management in all types and phases of shock includes the following:
Basic life support
Fluid replacement
Vasoactive medications
Nutritional support
A. Maintain patent airway and adequate ventilation.
B. Promote restoration of blood volume; administer fluid and bloodreplacement as ordered
C. Administer drugs as ordered
D. Minimize factors contributing to shock.
E. Maintain continuous assessment of the client.
F. Provide psychological support: reassure client to relieve apprehension, and keep family advised
G. Provide Nutritional support
Hypovolemic Shock
This is the MOST common form of shock characterized by a decreased intravascular volume
Risk factors: external Fluid Losses
Trauma, Surgery, Vomiting, Diarrhea, Diuresis, DI
Risk factors: internal fluid shifts
Hemorrhage, Burns, Ascites, Peritonitis, Dehydration

Decreased blood volume decreased venous return to the heart decreased stroke volume decreased cardiac output decreased tissue perfusion
Assessment findings: cold clammy skin, tachycardia, mental status changes, tachypnea

MEDICAL MANAGEMENT:
The major medical goals are to restore intravascular volume, to redistribute the fluid volume, and to correct the underlying cause of fluid
loss promptly

NURSNG MANAGEMENT:
Primary prevention of shock is the most important intervention of the nurse.
General nursing measures include- safe administration of the ordered fluids and medications, documenting their administration and effects.
The nurse must monitor the patient for signs of complications and response to treatment. Oxygen is administered to increase the amount of
O2 carried by the available hemoglobin in the blood.

CARDIOGENIC SHOCK
This shock occurs when the hearts ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues
Risk factors: Coronary factor- Myocardial infarction
Risks factors: NON coronary:
Cardiomyopathies
Valvular damage

Cardiac tamponade
Dysrhythmias

Precipitating factors will cause decreased cardiac contractility Decreased stroke volume and cardiac output leading to 3 things:
Damming up of blood in the pulmonary vein will cause pulmonary congestion
Decreased blood pressure will cause decreased systemic perfusion
Decreased pressure causes decreased perfusion of the coronary arteries leading to weaker contractility of the heart

ASSESSMENT FINDINGS: Angina, hemodynamic instability, dysrhythmias

MEDICAL MANAGEMENT:
The goals of medical management are to limit further myocardial damage and preserve and to improve the cardiac function by increasing
contractility.
NURSING MANAGEMENT:
The nurse prevents cardiogenic shock by early detection of patients at risk.
Safety and comfort measures like proper positioning, side-rails, and reduction of anxiety, frequent skin care and family education.

CIRCULATORY SHOCK

This is also called distributive shock. It occurs when the blood volume is abnormally displaced in the vasculature.
Septic Shock
Neurogenic Shock
Anaphylactic Shock

Massive arterial and venous dilation allows pooling of blood peripherally maldistribution of blood volume decreased venous return decreased
stroke volume decreased cardiac output Decreased blood pressure decreased tissue perfusion.

Risk factors for Septic Shock

Immunosuppression
Extremes of age (<1 and >65)
Malnourishment
Chronic Illness
Invasive procedures

Risk factors for Neurogenic Shock

Spinal cord injury
Spinal anesthesia
Depressant action of medications
Glucose deficiency

Risk factors for Anaphylactic Shock

Penicillin sensitivity
Transfusion reaction
Bee sting allergy
Latex sensitivity

SEPTIC SHOCK
This is the most common type of circulatory shock and is caused by widespread infection.
The HYPERDYNAMIC PHASE
High cardiac output with systemic vasodilatation.
The BP remains within normal limits.
Tachycardia
Hyperthermic and febrile with warm, flushed skin and bounding pulses
The HYPODYNAMIC or irreversible phase
LOW cardiac output with VASOCONSTRICTION
The blood pressure drops, the skin is cool and pale, with temperature below normal.
Heart rate and respiratory rate remain RAPID!
The patient no longer produces urine.
MEDICAL MANAGEMENT:
Current treatment involves identifying and eliminating the cause of infection. Fluid replacement must be instituted to correct Hypovolemia,
Intravenous antibiotics are prescribed based on culture and sensitivity.
NURSING MANAGEMENT:
The nurse must adhere strictly to the principles of ASEPTIC technique in her patient care.
Specimen for culture and sensitivity is collected. Symptomatic measures are employed for fever, inflammation and pain. IVF and
medications are administered as ordered.
Neurogenic Shock

This shock results from loss of sympathetic tone resulting to widespread vasodilatation.
The patient who suffers from neurogenic shock may have warm, dry skin and BRADYCARDIA!

MEDICAL MANAGEMENT:
This involves restoring sympathetic tone, either through the stabilization of a spinal cord injury or in anesthesia, proper positioning.

NURSING MANAGEMENT:
The nurse elevates and maintains the head of the bed at least 30 degrees to prevent neurogenic shock when the patient is receiving spinal or
epidural anesthesia.

Anaphylactic Shock

MEDICAL MANAGEMENT:
Treatment of anaphylactic shock requires removing the causative antigen, administering medications that restore vascular tone, and
providing emergency support of basic life functions.
EPINEPHRINE is the drug of choice given to reverse the vasodilatation

NURSING MANAGEMENT:
It is very important for nurses to assess history of allergies to foods and medications!
Drugs are administered as ordered and the responses to the drugs are evaluated.