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Transcript of Emergen. Bls&Shock
8/14/2019 Emergen. Bls&Shock
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Emergency Nursing: BLS
Prepared by:
Ms. Cherry Ann G. Garcia, RN
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Basic life support (BLS)
• A means of providing oxygen to
the brain, heart and other organs
until help arrives
• Also known as
CARDIOPULMONARY
RESUSCITATION
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Basic life support (BLS)
• 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
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Basic life support (BLS)
• The BLS follows the A-B-C principle
– A= airway
– B= breathing
– C= circulation
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Basic life support (BLS)
• Causes of cardiac arrest
– Respiratory arrest
– Direct injury – Drug overdose
– Cardiac arrhythmias
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Basic life support (BLS)
ADULT
• STEPS in CPR: First STEP
– ASSESSMENT: determine Unresponsiveness
– Assess for 5-10 seconds – Shake the victim’s shoulder and ask: “are you
okay”
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Basic life support (BLS)
ADULT
• STEPS in CPR: Second Step
– Survey the area
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Basic life support (BLS)
ADULT
• STEPS in CPR: Third Step
– Call for HELP
– Activate emergency medical system
– Note: for child and infant this is done LAST
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Basic life support (BLS)
ADULT
• STEPS in CPR: Fourth step
– Place Victim in Supine position on a flat firm
surface
– Log roll the patient when moving
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Basic life support (BLS)
ADULT
• STEPS in CPR: Fifth step
– OPEN the airway
– Head tilt-Chin Lift method
– Jaw thrust maneuver if neck injury is suspected
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Basic life support (BLS)
ADULT
• STEPS in CPR: Sixth step
– Assess BREATHING
• Place ear over the nose and mouth• Look for chest movement
• Perform for 3-5 SECONDS
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Basic life support (BLS)
ADULT
• STEPS in CPR: Sixth step
– Assess BREATHING
• If breathing: place on side if no neck injury; DONOT move if with neck injury
• If NOT BREATHING: deliver INITIALLY 2 rescuebreath via mouth to mouth
• Then deliver 10-12 breaths/minute
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Basic life support (BLS)
ADULT
• STEPS in CPR: Seventh step
– Assess CIRCULATION
• Check for the carotid pulse on the side close toyou for 5-10 SECONDS
• If with (+) pulse ; continue giving 10-12
breaths/minute
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Basic life support (BLS)
ADULT
• STEPS in CPR: Seventh 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 ½ to 2 INCHES
80-100 compressions/min
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Basic life support (BLS)
ADULT
• 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
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Basic life support (BLS)
CHILD
1-8 years old
• AIRWAY: assess unresponsivenessand keep airway patent by HTCL or JT
• BREATHING: assess for airflow andchest movement
• If breathing: maintain patentairway
• If NOT breathing : deliver 2rescue breaths by mouth tomouth
• DELIVER 20 breaths/minute
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Basic life support (BLS)
CHILD
1-8 years old
• CIRCULATION: assess the carotid pulse
• If with pulse: continue to deliver 15- 20 breaths/minute
• If WITHOUT pulse: start chestcompression
• Correct hand placement: lower half of sternum using heel of ONE HAND
• DELIVER: 1 to 1 ½ inches 80- 100 chest
compressions/min
5:1 (do 20 cycles EMS)
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Basic life support (BLS)
INFANT
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 rescuebreathing via mouth to mouth and nose
– DELIVER 20 breaths/min SLOWLY
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Basic life support (BLS)
INFANT
Less than 1
• CIRCULATION: assess for pulse: TheBRACHIAL pulse is utilized!!
– If with pulse: continue to deliver 20breaths/min
– If WITHOUT pulse, start chest compression
– Correct hand placement: just below thenipple line in the sternum using 2-3 fingers
of one hand!! – DELIVER: ½ to 1 inch depth
100 chest com/min
5:1 ratio (do 20 cycles EMS)
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AIRWAY Obstruction
• Incomplete
– Crowing sound is heard
encourage to cough
• Complete
– Clutching of the neck
– Ask: “Are you choking?”
– Perform Heimlich’s
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AIRWAY Obstruction
• 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 Heimlich’s TJL
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AIRWAY Obstruction
Pediatric consideration
CHILD: NEVER DO Blind Finger
sweep
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AIRWAY Obstruction
Obstetric considerations:
Hand is placed over the middle part
of sternum: backward chestthrust
If unconscious: place pillow below
the RIGHT abdomen to displace
uterus
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Shock
• An abnormal physiologic state
where an imbalance exists
between the amount of circulating
blood volume and the size of thevascular bed .
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Pathophysiology of Shock
1. Cellular effects of shock• In the absence of oxygen, the cell will undergo
Anaerobic metabolism to produce energy sourceand 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 enzymeswill be liberated, and then cellular death ensues.
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Pathophysiology of Shock
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
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Shock Stages
3 STAGES:
• Compensatory stage• Progressive stage
• Irreversible stage
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Shock Stages
THE COMPENSATORY STAGE OF SHOCK
• In this stage, the patient’s blood pressure is withinnormal limits.
• Patient’s blood is shunted from the kidney, skin and GITto 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 tissueperfusion & vital signs, reduction of anxiety,administering IVF/ordered medications and promotion of safety
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THE PROGRESSIVE STAGE OF SHOCK
• In this stage, the mechanisms that regulate blood pressurecan no longer compensate and the mean arterial pressurefalls.
• The overworked heart becomes dysfunctional. Heart ratebecomes very rapid (as high as 150 bpm)
• Blood flow to the brain becomes impaired, the mentalstatus deteriorates due to decreased cerebral perfusionand hypoxia.
• Laboratory findings will reveal increased BUN andCreatinine. Urinary output decreases to below 30 mL/hour.
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THE PROGRESSIVE STAGE OF SHOCK
• 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, metabolicacidosis (due to accumulation of lactic acid),
and generalized hypoxemia can interfere
with normal blood function.
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THE IRREVERSIBLE STAGE OF SHOCK
• This stage represents the end point where there issevere organ damage that patients do not respond anymore to treatment. Survival is almost impossible tomaintain.
• Despite treatment, the BP remains low, anaerobicmetabolisms continues and multiple organ failure results.
• Medical management is the use of life supporting drugslike epinephrine and investigational medications.
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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.
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Assessment of ShockAssessment Findings
Respirations: rapid and shallow, due to tissue anoxia andexcessive 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).
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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
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Management of ShockA. Maintain patent airway and adequate ventilation.
B. Promote restoration of blood volume; administer fluid andbloodreplacement 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 relieveapprehension, and keep family advised
G. Provide Nutritional support
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Hypovolemic Shock
This is the MOST common form of shock characterizedby 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
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Hypovolemic Shock
• Decreased blood volume decreased venousreturn to the heart decreased stroke volume decreased cardiac output decreased tissueperfusion
• Assessment findings: cold clammy skin,tachycardia, mental status changes, tachypnea
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Hypovolemic Shock
• MEDICAL MANAGEMENT: – The major medical goals are to
restore intravascular volume, toredistribute the fluid volume, and
to correct the underlying cause of fluid loss promptly
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Hypovolemic Shock
• NURSNG MANAGEMENT:
– Primary prevention of shock is the most
important intervention of the nurse.
– General nursing measures include- safe
administration of the ordered fluids andmedications, 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 availablehemoglobin in the blood.
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Cardiogenic shock• 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 willcause pulmonary congestion
• Decreased blood pressure will cause decreased
systemic perfusion• Decreased pressure causes decreasedperfusion of the coronary arteries leading toweaker contractility of the heart
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Circulatory shock• This is also called distributive shock. It occurs when
the blood volume is abnormally displaced in thevasculature.
– Septic Shock
– Neurogenic Shock
– Anaphylactic Shock
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Circulatory shock• Risk factors for Septic Shock
–Immunosuppression
–Extremes of age (<1 and >65)
–Malnourishment
–Chronic Illness
–Invasive procedures
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Circulatory shock
• Risk factors for Neurogenic Shock
–Spinal cord injury
–Spinal anesthesia
–Depressant action of medications
–Glucose deficiency
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Circulatory shock• Risk factors for Anaphylactic Shock
–Penicillin sensitivity
–Transfusion reaction
–Bee sting allergy
–Latex sensitivity
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SEPTIC SHOCKThis 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 andbounding pulses
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SEPTIC SHOCK
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.
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SEPTIC SHOCK
• 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 andsensitivity.
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SEPTIC SHOCK
• 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.
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Neurogenic ShockThis 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!
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Neurogenic Shock
• MEDICAL MANAGEMENT:
– This involves restoring sympathetic tone, either through
the stabilization of a spinal cord injury or in anesthesia,
proper positioning.
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Neurogenic Shock
• 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.
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Anaphylactic Shock• MEDICAL MANAGEMENT:
– Treatment of anaphylactic shock requires removing thecausative antigen, administering medications that restorevascular tone, and providing emergency support of basiclife functions.
– EPINEPHRINE is the drug of choice given to reverse thevasodilatation
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Triage
• “trier”- to sort
• To sort patients in groups based on the
severity of their health problem and the
immediacy with which these problems
must be addressed
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Triage in the E.R.
• Berner’s
1. Emergent
2. Urgent
3. Non-urgent
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Triage in DISASTER!
• NATO
1. Immediate
2. Delayed
3. Minimal
4. Expectant
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Triage1. Emergent
– Patients have the highest priority
– With life-threatening condition
2. Urgent – Patients with serious health problems
– Not life-threatening, MUST be seen in 1 hour 3. Non-urgent
– Episodic illness that can be addressed within 24 hours
Triage category
Priority Color Conditions
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Triage in Disaster
g g y y
Immediate 1 RED Chest wounds, shock,open fractures, 2-3
burns
Delayed 2 YELLOW Stable abdominalwound, eye and CNSinjuries
Minimal 3 GREEN Minor burns, minor fractures, minor bleeding
Expectant 4 BLACK Unresponsive, highspinal cord injury
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Preparing for terrorism
1. Recognition and Awareness
2. Use of personal protective equipments
3. Decontamination of contaminants
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Biological Weapons
ANTHRAX
• Drug of choice is Ciprofloxacin or
Doxycycline
SMALLPOX
• Supportive
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Chemical Weapons
Organophosphates – Supportive care
– Soap and water
– Atropine
– Pralidoxine
Cyanide
– Sodium nitrite, Amyl Nitrite, Methylene Blue
– Sodium thiosulfate
– Hydrocobalamin
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CYANIDE POISONING
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Radiation
Alpha Particles Cannot penetrate skin
Causes local damage
Beta Particles Moderately penetrate the skin
Can cause skin damage and internalinjury if prolonged
Gamma Particles Penetrate skinCan cause serious damage
X-ray is an example