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A NURSE’S GUIDE
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Judith A. Schilling McCann,
H. Nancy Holmes
Joan M. Robinson, RN, MSN
Senior Art Director
Editorial Project Manager
Clinical Project Manager
Mary Perrong, RN, CRNP, MSN,
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Kimberly Bilotta (supervisor),
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Digital Composition Services
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(director), Beth J. Welsh
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Karen J. Kirk, Linda K. Ruhf
The clinical treatments described and recommended in this publication are based on research and consultation with nursing, medical, and legal authorities. To the best of our
knowledge, these procedures reflect currently
accepted practice. Nevertheless, they can’t be
considered absolute and universal recommendations. For individual applications, all recommendations must be considered in light of
the patient’s clinical condition and, before administration of new or infrequently used
drugs, in light of the latest package-insert information. The authors and publisher disclaim
any responsibility for any adverse effects resulting from the suggested procedures, from
any undetected errors, or from the reader’s
misunderstanding of the text.
© 2006 by Lippincott Williams & Wilkins. All
rights reserved. This book is protected by
copyright. No part of it may be reproduced,
stored in a retrieval system, or transmitted, in
any form or by any means — electronic, mechanical, photocopy, recording, or otherwise — without prior written permission of
the publisher, except for brief quotations embodied in critical articles and reviews and
testing and evaluation materials provided by
publisher to instructors whose schools have
adopted its accompanying textbook. Printed
in China. For information, write Lippincott
Williams & Wilkins, 323 Norristown Road,
Suite 200, Ambler, PA 19002-2756.
Library of Congress
Rapid response to everyday emergencies: a
p. ; cm.
Includes bibliographical references and index.
1. Emergency nursing — Handbooks, manuals,
etc. I. Lippincott Williams & Wilkins.
[DNLM: 1. Nursing Care — methods — Handbooks. 2. Emergency Nursing — methods —
Handbooks. WY 49 R218 2006]
610.73'6 — dc22
ISBN10: 1-58255-430-7 (alk. paper) 2005002797
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Contributors and consultants
Endocrine and metabolic emergencies
Obstetric and gynecologic emergencies
Eye, ear, nose, and throat emergencies
Emergencies due to drug toxicity and overdose
Emergency cardiac drugs
Normal and abnormal serum drug levels
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Contributors and consultants
Haralee Abramo, RN, MSN
Sharon Lee, RN, MS, BSN, FNP, CCRN
Director of Education
Los Robles Hospital and
Thousand Oaks, Calif.
Family Nurse Practitioner,
Bryan LGH Medical Center
Karen Balich-Reitz, RN, MS
Elizabeth Molle, RN, MS
Anne L. Bateman, RN, EdD, APRN,BC, PMH
Ruthie Robinson, RN, MSN, CCRN, CEN, CNS
Assistant Professor, Nursing and
University of Massachusetts
Director, Magnet Program and
Christus St. Elizabeth Hospital
Laura M. Criddle, RN, MS, CEN, CCNS,
Belinda L. Spencer, RN, MSN, CCRN,
Oregon Health and Science
Army Trauma Training Center
Ryder Trauma Center
Cynthia L. Dakin, RN, PhD
Warren Stewart, RN, BSN, CEN
Irwin Army Community Hospital
Ft. Riley, Kans.
Laura Favand, RN, BSN, MS
Robin Walsh, RN, BSN, CEN
Chief Nurse Education and
Army Trauma Training Center
Ryder Trauma Center
Clinical Nurse Supervisor
University Health Services at the
University of Massachusetts
Rita M. Wick, RN, BSN
Berkshire Health Systems
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As a nursing student, I longed to work in an exciting, high-acuity practice
setting. After graduation, as I began my career in the real world of professional nursing, I quickly learned that true emergencies can be terrifying
events, especially to a novice. An interesting dichotomy emerged: Despite
my initial desire to work in an action-packed setting, I suddenly wanted
all of my patients to be absolutely stable. Each new crisis challenged my
ability to respond competently and effectively cope with the aftermath of
my actions. I would replay each scenario in my mind and wonder if I
could have done anything differently.
It was a frustrating experience.
I eventually learned my lessons, but it wasn’t easy. In those days,
emergency care algorithms and protocols weren’t widely available or even
taught to most nurses. We were expected to adapt — and because of that,
the stress and strain of learning how to rapidly respond weighed upon me
Luckily for you, Rapid Response to Everyday Emergencies: A Nurse’s
Guide is an all-new title specifically designed to demystify emergency situations by providing vital emergency-response information in a quickscan format. This user-friendly handbook gives students and experienced
nurses alike a practical need-to-know clinical reference that offers prioritized, highly bulleted guidance for instant crisis management.
The book’s concise yet highly detailed structure is just one of many
innovations that make it such a valuable reference. It begins with a chapter
on emergency essentials, which includes an overview of how to conduct
primary and secondary surveys — tools that, if used properly, rapidly identify life-threatening emergencies and enable you to prioritize your care.
This chapter also discusses triage and basic life-support guidelines, which
are two aspects of nursing care that every nurse should occasionally brush
The rest of the book is broken down into chapters by either body system or trauma type, and the disorders in each chapter are listed in alphabetical order to facilitate its quick-access format. Forget about paging
through this book to find what you need. Rapid Response to Everyday
Emergencies: A Nurse’s Guide allows you to locate information in a flash.
Once you’re at the entry, the book speeds you along even faster.
Crucial information pertinent to each emergency is presented up-front for
easy access; pathophysiology and other background content follows. Just
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the right amount of supplemental information allows for a critique of the
event and a discussion of clinical issues surrounding the emergency.
In addition to the core text, Rapid Response to Everyday Emergencies:
A Nurse’s Guide emphasizes key points in a variety of ways. Sidebars
filled with insightful information abound, and eye-catching logos draw attention to some of the most important clinical points. In Action presents
case studies of actual emergencies and provides in-depth analysis on how
to best manage them. Complications highlights warning signs and symptoms to monitor for and the actions to take should they develop. Alert details crucial points in the management of crisis situations. The inclusion of
appendices on emergency cardiac drugs and normal and abnormal serum
drug levels enhance the book’s overall utility.
In my experience, knowledge, focus, and anticipation are essential in
emergency management. Knowledge involves recognition of the situation
through assessment and critical thinking, as well as prioritizing actions.
Focus is necessary to block out extraneous information and concentrate on
critical aspects of care. Anticipation is vital to stay one step ahead, be prepared for complications that may arise, and to plan for ways to prevent the
emergency altogether. Rapid Response to Everyday Emergencies: A Nurse’s
Guide illustrates this approach like no other book on the market. It’s a part
of my reference library, and I highly recommend that it become a part of
Linda Laskowski-Jones, RN, MS, APRN,BC, CCRN, CEN
Director, Trauma, Emergency & Aeromedical Services
Christiana Care Health System – Christiana Hospital
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What comes to mind when you hear the word emergency? Do you think of
a motor vehicle accident, a drowning, or a patient with cardiac arrest coming through the doors of the emergency department (ED)? Or, do you visualize a postoperative patient experiencing respiratory distress or a patient
falling while trying to walk to the bathroom? Emergencies occur everywhere. No matter what your area of expertise, you’ll encounter emergencies in your nursing career. This chapter will give an overview of emergency situations and your role in responding to patients who need your
When a patient arrives in the ED by ambulance, it’s important to get
as much information as you can from the prehospital care providers. For
instance, if the patient was involved in an accident, you’ll want to know
the following information:
➤ Mechanism of injury — How did the accident occur? What type of accident was it? If it was a motor vehicle accident, did the vehicle sustain
exterior or interior damage? Was the patient restrained? Did the patient
have to be extricated from the vehicle? Was he ambulatory at the scene?
If the patient sustained a burn injury, was he found in an enclosed
space? If the burn resulted from a fire, was the fire accompanied by an
➤ Injuries sustained — What injuries have the prehospital care providers
identified or suspected? What are the patient’s chief complaints?
➤ Vital signs — What vital signs have they obtained before arriving in the
➤ Treatment — What treatment have they provided to the patient and how
did he respond?
Prehospital care providers can give invaluable information to expedite diagnosis and treatment of the patient.
All patients with traumatic injuries should be assessed rapidly in a
systematic method used consistently for all patients. The Emergency
Nurses Association (ENA) has developed the Trauma Nursing Core Course
to teach nurses such a method for assessing trauma patients. The ENA
method uses primary and secondary surveys to rapidly identify lifethreatening emergencies and prioritize care; these surveys are reviewed
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The primary survey begins with an assessment of airway, breathing, and
circulation — the ABCs learned in nursing school. The ENA recommends
additional assessment parameters — neurologic status, designated as disability (D), and exposure and environment, designated as (E). (See Primary
assessment of the trauma patient.) The ABCDE primary survey consists of
➤ A: Before you assess the airway of a trauma patient, immobilize the cervical spine by applying a cervical collar. Until proven otherwise, assume that the patient who has sustained a major trauma has a cervical
spine injury. When continuing your assessment, note whether the patient can speak; if he can, he has a patent airway. Check for obstructions
to the airway, such as the tongue (the most common obstruction), blood,
loose teeth, or vomitus. Clear airway obstructions immediately, using
the jaw thrust or chin lift technique to maintain cervical spine immobilization. You may need to use suction if blood or vomitus are present.
Insert a nasopharyngeal or oropharyngeal airway if necessary — but remember that an oropharyngeal airway can only be used on an unconscious patient. An oropharyngeal airway stimulates the gag reflex in a
conscious or semi-conscious patient. If a nasopharyngeal or oropharyngeal airway fails to provide a patent airway, the patient may require intubation.
➤ B: Assess the patient for spontaneous respirations, noting their rate,
depth, and symmetry. Obtain oxygen saturation with pulse oximetry. Is
he using accessory muscles to breathe? Do you hear breath sounds bilaterally? Do you detect tracheal deviation or jugular vein distention? Does
the patient have an open chest wound? All major trauma patients require high-flow oxygen. If the patient doesn’t have spontaneous respirations or if his breathing is ineffective, ventilate him by using a bagvalve-mask device until intubation can be achieved.
➤ C: Check for the presence of peripheral pulses. Determine the patient’s
blood pressure. What’s his skin color — does he exhibit pallor, flushing,
or some other discoloration? What’s his skin temperature — is it warm,
cool, or clammy to the touch? Is the patient diaphoretic? Is there obvious bleeding? All major trauma patients need at least two large-bore I.V.
lines because they may require large amounts of fluids and blood. A fluid warmer should be used if possible. If the patient exhibits external
bleeding, apply direct pressure over the site. If he has no pulse, initiate
cardiopulmonary resuscitation immediately.
➤ D: Perform a neurologic assessment. Use the Glasgow Coma Scale to assess the patient’s baseline mental status. You may also assess the patient
using the mnemonic AVPU, in which A represents an alert and oriented
patient, V indicates response to voice, P represents response to pain,
and U indicates an unresponsive patient. Maintain cervical spine immobilization until X-rays confirm that there’s no cervical injury. If the
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➤ PRIMARY ASSESSMENT OF THE TRAUMA PATIENT
A ϭ Airway
➤ Airway patency
➤ Institute cervical spine immobi-
lization until X-rays determine
whether the patient has a cervical
➤ Position the patient.
➤ To open the airway, make sure
that the neck is midline and stabilized; next, perform the jaw-thrust
B ϭ Breathing
➤ Respirations (rate, depth,
➤ Breath sounds
➤ Chest wall movement and
➤ Position of trachea (midline or deviation)
C ϭ Circulation
➤ Pulse and blood pressure
➤ Bleeding or hemorrhage
➤ Capillary refill and color of
skin and mucous membranes
➤ Cardiac rhythm
D ϭ Disability
E ϭ Exposure
➤ Administer 100% oxygen with a
➤ Use airway adjuncts, such as an
oropharyngeal or a nasopharyngeal
airway, an endotracheal tube, an
esophageal-tracheal combitube, or
cricothyrotomy, as indicated.
➤ Suction the patient as needed.
➤ Remove foreign bodies that may
➤ Treat life-threatening conditions,
such as pneumothorax or tension
➤ Start cardiopulmonary resuscita-
tion, medications, and defibrillation
or synchronized cardioversion.
➤ Control hemorrhaging with
direct pressure or pneumatic
➤ Establish I.V. access and fluid
therapy (isotonic fluids and blood).
➤ Treat life-threatening conditions
such as cardiac tamponade.
➤ Neurologic assessment,
➤ Institute cervical spine immobi-
including level of consciousness, pupils, and motor and
lization until X-rays confirm the
absence of cervical spine injury.
➤ Environmental exposure
➤ Examine the patient to determine
(extreme cold or heat) and
➤ Institute appropriate therapy
the extent of injuries.
determined by environmental exposure (warming therapy for hypothermia or cooling therapy for
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patient isn’t alert and oriented, conduct further assessments during the
➤ E: Expose the patient to perform a thorough assessment. Remove all
clothing to assess all of his injuries. Remember, if the patient has bullet
holes or knife tears through his clothing, don’t cut through these areas.
Law enforcement will count on you to preserve evidence as necessary.
Environmental control means keeping the patient warm. Remember,
you have removed all of the patient’s clothes. Cover him with warm
blankets. You may need to use an overhead warmer, especially with an
infant or a small child. Use fluid warmers when administering large
amounts of I.V. fluids or blood. A cold patient has numerous problems
Remember that the primary ABCDE survey is a rapid assessment intended to identify life-threatening emergencies, which must be treated before the assessment continues.
After the primary survey is completed, perform a more detailed secondary
survey, which includes a head-to-toe assessment. This part of the examination identifies all injuries sustained by the patient. At this time, a care plan
is developed and diagnostic tests are ordered.
➤ Obtain a full set of vital signs initially including respirations, pulse,
blood pressure, and temperature. If you suspect chest trauma, get blood
pressures in both arms.
Next, perform the five interventions:
– Initiate cardiac monitoring.
– Obtain continuous pulse oximetry readings. Be aware, however, that
readings may be inaccurate if the patient is cold or in hypovolemic
– Insert a urinary catheter to monitor accurate intake and output measurements. Many urinary catheters also record core body temperatures.
Don’t insert a urinary catheter if there’s blood at the urinary meatus.
– Insert a nasogastric (NG) tube for stomach decompression. Injuries,
such as a facial fracture, contraindicate the use of an NG tube; if a facial
fracture is suspected, insert the tube orally instead. Depending on your
facility’s policy and procedures, the physician may insert the NG tube
when facial fracture is suspected.
– Obtain laboratory studies as ordered, such as type and crossmatching
for blood; a complete blood count or hematocrit and hemoglobin level;
toxicology and alcohol screens, if indicated; a pregnancy test, if necessary; and serum electrolyte levels.
➤ Facilitate the presence of the patient’s family. Several organizations, including the ENA and the American Heart Association, endorse the practice of allowing the patient’s family to be present during resuscitation.
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➤ MEMORY TIP: SAMPLE
The acronym SAMPLE is a mnemonic that will help you remember the types of
information you’ll need to obtain for the patient’s history.
SUBJECTIVE: What does the patient say? How did the accident occur? Does he
remember? What symptoms does he report?
ALLERGIES: Does the patient have allergies and if so, to what is he allergic? Is
he wearing a MedicAlert bracelet?
MEDICATIONS: Does the patient take medications on a regular basis and if so,
what medications? What medications has he taken in the past 24 hours?
PAST MEDICAL HISTORY: Has the patient been treated for medical conditions
and if so, what condition(s)? Has he had surgery and if so, what type of
LAST MEAL EATEN/LAST TETANUS SHOT/LAST MENSTRUAL PERIOD: When was the
last time the patient had anything to eat or drink? When did he have his most
recent tetanus shot? (If unknown, administer one in the emergency department.) If the patient is a female of childbearing age, when was her last menstrual period? Could she be pregnant?
EVENTS LEADING TO INJURY: How did the accident occur? Inquire about precipitating factors, if any. For instance, the patient being seen for injuries sustained
in a motor vehicle accident may have had the accident because he experienced
a myocardial infarction while driving. Likewise, the patient who sustained a fall
might have fallen because he tripped or became dizzy.
It’s important, however, to assess the family’s needs before offering permission to be present. Family members may need emotional and spiritual support from you or from a member of the clergy. If a family member wishes to be present during resuscitation, assign a medical professional to explain procedures as they’re performed.
Calm the patient’s fears. During a tense trauma situation, the urgency of
the assessment and treatment processes may cause you to overlook the
patient’s fears. Remember to talk to the patient and explain the examination and interventions being administered. An encouraging word and
tone can go a long way to comfort and calm a frightened patient.
Comfort measures also include the administration of pain medication
and sedation as needed.
Obtain the patient’s history, remembering to obtain as much information
as possible to determine the presence of coexisting conditions that
could affect his care or factors that might have precipitated the trauma.
(See Memory tip: SAMPLE.) Next, perform a head-to-toe assessment,
starting at the patient’s head and working your way down to his feet.
Don’t forget to check all posterior surfaces. Logroll the patient (with as-
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sistance, if necessary) to assess for injuries to the back. Address any lifethreatening injuries immediately.
Triage is a method of prioritizing patient care according to the type of illness or injury and the urgency of the patient’s condition. It’s used to ensure that each patient receives care appropriate to his need and in a timely
Many people with nonurgent conditions come to the ED because it’s
their only source of medical care; this increase in nonurgent cases has necessitated a means of quickly identifying and treating those patients with
more serious conditions. The triage nurse must be able to rapidly assess
the nature and urgency of problems for many patients and prioritize their
care based on that assessment.
The ENA has established guidelines for triage based on a five-tier system:
➤ Level I — resuscitation: This level includes patients who need immediate nursing and medical attention, such as those with cardiopulmonary
arrest, major trauma, severe respiratory distress, and seizures.
➤ Level II — emergent: These patients need immediate nursing assessment
and rapid treatment. Patients who may be assessed as level II include
those with head injuries, chest pain, stroke, asthma, and sexual assault.
➤ Level III — urgent: These patients need quick attention, but can wait as
long as 30 minutes for assessment and treatment. Such patients might
report to the ED with signs of infection, mild respiratory distress, or
➤ Level IV — less urgent: Patients in this triage category can wait up to an
hour for assessment and treatment; they might include those with an
earache, chronic back pain, upper respiratory symptoms, and a mild
➤ Level V — nonurgent: These patients can wait up to 2 hours (possibly
longer) for assessment and treatment; those with sore throat, menstrual
cramps, and other minor symptoms are typically assigned to level V.
If you can’t decide which triage level is best for a patient, assign him
the higher level.
Carefully document the patient’s chief complaint and vital signs, your
triage assessment, and the triage category to which you’ve assigned him.
It’s also important to document pertinent negatives. For example, if the patient is experiencing chest pain without cardiac symptoms, be sure to note
“Patient complains of nonradiating left chest pain. Denies shortness of
breath, diaphoresis, or nausea. Pain increases with movement and deep inspiration.” Quote the patient when appropriate.
As you perform triage, tell the patients you interview that you are the
triage nurse and that you’ll be performing a screening assessment. Be attentive to what’s occurring beyond your current assessment because it may
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Emergencies throughout the hospital
be necessary to leave the patient if a patient with a more critical situation
arrives in the ED. Maintain communication with patients waiting to be
summoned to a treatment room because a patient’s status may change —
improving or worsening — during an extended period in the waiting room.
Emergencies throughout the hospital
It’s no surprise that emergencies aren’t confined to the ED — they occur
throughout the facility and you need to be prepared to respond regardless
of the unit to which you’re assigned.
Responding to an emergency situation always begins with the
ABCDEs discussed earlier. Likewise, basic life support (BLS) is always
performed the same way, whether it’s done within or outside the ED. The
American Heart Association BLS algorithm provides the following guidelines:
➤ Check responsiveness — call the patient and gently shake or tap him to
see if there’s a response.
➤ If no response, call for help.
➤ Open the airway — use the head tilt/chin lift method.
➤ Check breathing — look, listen, and feel for respirations.
➤ Breathe — if the patient isn’t breathing, give two full breaths.
➤ Assess circulation — assess for signs of circulation for 10 seconds only.
➤ If circulation is present — continue rescue breathing and reassess circulation every minute.
➤ If circulation isn’t present — begin chest compressions.
Patients experiencing cardiopulmonary arrest are managed with BLS
as described above until advanced cardiac life support (ACLS) measures
are available. ACLS involves advanced airway techniques (intubation), defibrillation, and emergency drug administration.
Falls are a commonly encountered emergency in most facilities.
Again, assessing the ABCDEs is the first step in caring for the patient who
has fallen. Follow the primary survey with the secondary survey. Assist
the patient back to bed if possible. Document your findings in the medical
record. Notify the primary care provider that the patient fell. Most facilities also require that you file an incident report when a patient falls. Reviewing the report, which documents the circumstances of the fall, may
enable the staff to institute measures that will prevent or decrease the incidence of falls. Every patient should be assessed for fall risk upon admission and appropriate fall precautions instituted as needed.
Respiratory distress is another common emergency. Respiratory difficulties can be caused by many conditions, such as fluid overload, asthma,
allergic reactions, and pulmonary embolus. In addition to the ABCDEs, it’s
important to provide verbal reassurance to the patient in respiratory distress to decrease his anxiety. Administer supplemental oxygen and, if not
contraindicated, raise the head of the bed to ease respiratory effort. The
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patient may find it helpful to hang his legs off the side of the bed and lean
on an overbed table. If he needs to assume this position, remain with him
to prevent falls. Notify the primary care provider as soon as possible. Anticipate orders for a chest X-ray, arterial blood gas levels, an electrocardiogram, or a breathing treatment. The patient’s history and reason for hospitalization can help you identify the reason for the respiratory distress.
An anaphylactic reaction is a severe allergic reaction that constitutes
a life-threatening emergency situation; untreated anaphylaxis can lead to
bronchoconstriction, circulatory collapse, and death. If the patient is receiving blood products, immediately discontinue them and replace with
normal saline solution administered through new I.V. tubing. (Initiate an
I.V. line if not already present.) Raise the head of the bed and apply highflow oxygen. Notify the primary care provider immediately and have epinephrine available for administration. Other drugs that may be used to
treat an anaphylactic reaction include antihistamines and corticosteroids.
Discharge teaching for this patient will include wearing a MedicAlert
bracelet and, possibly, carrying an epinephrine kit at all times.
Loss of consciousness
A patient may experience loss of consciousness due to numerous conditions. His history and reason for hospitalization will provide clues to the
etiology of the event, and the cause will guide the treatment. A few potential causes of loss of consciousness are listed below.
➤ Alcohol or drugs — Even the hospitalized patient may consume alcohol
or drugs; he could have brought the substances into the facility himself
or a visitor might have brought them. Do you smell alcohol on the patient’s breath? Is there a history of alcohol consumption? Is there evidence of track marks? What’s the patient’s pupillary response? Is the
breathing shallow? Does the patient respond to naloxone (Narcan)?
➤ Seizures — Is it possible that the patient has suffered a seizure? Is there
a history of seizures? Has the patient experienced bladder or bowel incontinence?
➤ Metabolic disturbances — Does the patient have a history of liver or renal failure? Diabetes? Check the blood glucose level at the bedside. If
the patient is hypoglycemic, does he respond to I.V. dextrose?
➤ Head trauma — Has the patient recently suffered head trauma? An elderly patient can experience a subdural hematoma days after a head injury.
➤ Stroke — If a stroke is suspected, a computed tomography scan of the
brain will be needed.
➤ Infection — Has the patient exhibited signs or symptoms of meningitis
Remember that a loss of consciousness is scary for the patient. Not
only may he require treatment for injuries resulting from the loss of consciousness, he may also require emotional support.
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Acute peripheral arterial occlusion
Peripheral arterial occlusion is an obstruction in a healthy artery or an
artery with progressive atherosclerosis caused by embolism, thrombosis,
or trauma. Arterial blood flow is occluded, and distal tissues become deprived of oxygen. Ischemia and infarction may follow.
Examine the affected limb for the five Ps — pain, pulselessness, paresthesia, pallor, and paralysis:
➤ Pain — usually severe and sudden in an arm or leg (or in both legs in a
patient with a saddle embolus)
➤ Pulselessness — diminished or absent arterial pulses when checked by
Doppler and decreased or absent capillary refill
➤ Paresthesia — numbness, tingling, paresis, or a sensation of cold in the
➤ Pallor — a line of color and temperature demarcation at the level of the
➤ Paralysis — some degree of limb paralysis.
ALERT Paralysis is a late sign of ischemia. Even after blood flow
is restored, a patient may have paralysis and neuropathy.
Ask the patient if he has a history of:
chronic arrhythmias such as atrial fibrillation
drug use that may contribute to thrombus or embolus formation (such
as hormonal contraceptives)
If you suspect an acute arterial occlusion:
➤ Notify the physician.
➤ Place the patient on bed rest.
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Place the affected area in a dependent position to enhance blood flow.
Give supplemental oxygen.
Insert an I.V. catheter in an unaffected limb.
Draw blood for diagnostic studies.
Administer analgesics, such as morphine, possibly I.V. (to achieve adequate pain relief), heparin (to prevent further emboli formation), and
thrombolytics (to dissolve a newly formed clot), as ordered.
Perform frequent neurovascular checks.
Mark the location on the patient’s extremity where the pulses are palpable or audible to ensure consistent assessments.
Document the status of each pulse immediately after each assessment,
compare findings, and report changes immediately.
Mark areas of discoloration or mottling on the patient’s extremity and
notify the physician of any area expansion.
Watch for tissue swelling after successful thrombolytic therapy.
Monitor prothrombin time, International Normalized Ratio, and partial
thromboplastin time and other coagulation panels.
Report values outside therapeutic levels.
Watch for signs of bleeding.
Prepare the patient for interventional radiology (angioplasty or stenting)
or surgery (thrombectomy, arterial bypass, or amputation).
Avoid clothing that restricts blood flow to the affected area.
Prevent trauma to the affected area by using a soft-care mattress, cotton
wraps or protectors for the heels, a foot cradle, and sheepskin.
Avoid the use of heating pads or cold packs, to prevent burns.
Perform teaching related to bleeding precautions and the effects of anticoagulants and thrombolytics.
Provide a diet low in vitamin K (the antidote to warfarin).
Prophylactic anticoagulation is essential for patients at highest risk.
Instruct patients that smoking cessation may prevent episodes of arterial
A clot in a peripheral artery hinders or stops blood flow to a specific
The area is then deprived of oxygen and begins to experience cellular
and tissue changes, which may progress to necrosis and, possibly,
Risk factors include smoking, aging, intermittent claudication, diabetes
mellitus, chronic arrhythmias, hypertension, hyperlipidemia, and using
drugs that may contribute to thrombus or embolus formation such as
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An air embolism is a potentially lethal condition that occurs when air bubbles enter the circulatory system.
Assess the rate, depth, pattern, and quality of respirations, noting dyspnea and tachypnea.
Assess the patient’s level of consciousness, noting confusion and lethargy.
Obtain the patient’s vital signs, including oxygen saturation.
Ask about chest or joint pain.
Abort a central venous (CV) line insertion attempt, clamp the line, and
leave it in place.
Place the patient on his left side with his head down in Trendelenburg
Provide 100% oxygen and prepare for endotracheal intubation and
mechanical ventilation, if necessary.
Notify the physician.
During surgery, assist the surgeon to seal open blood vessels.
Insert a peripheral I.V. line and administer I.V. fluids. (See Managing air
embolus, pages 12 and 13.)
Aspirate from the distal port of a CV catheter, if present, and attempt to
Perform external cardiac compression in the case of cardiovascular collapse.
Administer hyperbaric oxygen therapy.
Prepare the patient for a transesophageal echocardiogram, Doppler
ultrasound, and pulmonary artery catheter placement, as ordered.
Administer beta-adrenergic blockers and, if seizures occur, anticonvulsants.
Eliminate air from the contents of a syringe before injecting its contents,
and prime all I.V. fluid tubing.
Place the patient in Trendelenburg position during CV line insertion.
Use closed catheterization systems.
Apply an occlusive dressing to the catheter site after CV catheter removal.
ALERT Air embolism may be delayed for 30 minutes or more after
catheter removal. Monitor the patient for 1 hour after removal for
signs and symptoms to be safe.
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➤ MANAGING AIR EMBOLUS
You’re helping Paul Stone, 55, to get
out of bed and walk. He’s taken only
a few steps when he starts having difficulty breathing and complains of
pain in his mid-chest and shoulder.
He suddenly becomes very pale and
says he feels nauseated and lightheaded.
What’s the situation?
Mr. Stone had a small bowel resection 2 days ago. This is his first
attempt to walk postoperatively. He
has a triple-lumen central vascular
catheter inserted via the subclavian
You call for assistance and help
Mr. Stone back to bed. The dressing
is still intact, but you notice a small
amount of fluid on the floor. The
junction of the catheter hub and tubing are outside the dressing, and you
see that the tubing has pulled apart
from one of the catheter hubs.
What’s your assessment?
Based on Mr. Stone’s signs and
symptoms, you suspect an air embolus. The insertion site for his central
vascular catheter is above the level of
the heart, and Mr. Stone was standing
when the tubing separated from the
catheter hub. The venous pressure at
the catheter tip is lower than the
atmospheric pressure. When Mr.
Stone took a breath, air was sucked
into the right side of his heart
through the open catheter lumen.
A large air bubble blocks blood
flow from the right ventricle into the
pulmonary artery. Blood continues to
flow into the right side of the heart,
causing it to pump harder. This
increased workload and increased
pressure of the right ventricle causes
more air bubbles to break away from
the air pocket and forces them into
the pulmonary artery. This may result
in decreased cardiac output, shock,
What must you do
Close the open catheter lumen with
the slide clamp on the catheter’s
extension leg or with another clamp
such as a hemostat. If no other clamp
is available, manually fold and pinch
the tubing together.
Place Mr. Stone on his left side in
the Trendelenburg position to move
the air embolus away from the pulmonic valve.
Take his vital signs: heart rate, 140;
respirations, 30; BP, 90/60 mm Hg.
You listen to his chest and hear a continuous churning sound, a classic indication of an air embolus (although
this sign isn’t always present). His
color is becoming cyanotic and he’s
still short of breath. You immediately
administer 100% oxygen and page
the surgeon stat. Oxygen causes the
nitrogen in the air embolus to dissolve into the blood. The air bubble
decreases in size as nitrogen moves
into the blood. For very large air
emboli, hyperbaric therapy may be
needed to increase this process. Next,
insert a peripheral I.V. line for emergency vascular access. Obtain specimens for arterial blood gas studies
and prepare the patient for an electrocardiogram, which may show
sinus tachycardia and nonspecific STsegment and T-wave changes. Initially, a chest X-ray may be normal, but
subsequent X-rays will probably
430702.qxd 3/17/05 3:53 AM Page 13
MANAGING AIR EMBOLUS (continued)
show pulmonary edema, which can
develop after an air embolus.
What should be done later?
If Mr. Stone continues to have symptoms for more than a few hours,
other treatment may be necessary.
The central vascular catheter may be
used to aspirate the embolus, or the
physician may insert a needle into the
right ventricle percutaneously and
aspirate the air embolus.
Because of your quick action with
proper patient positioning and oxygen, Mr. Stone begins to stabilize
within an hour after the catheter disconnection. Because air embolism is a
significant risk for a patient with a
central vascular catheter, always use
tubing with a twist-lock connection
and check all junctions frequently to
make sure that they’re secure, especially before the patient gets out of
Hadaway, L.C. “Action Stat: Air embolus,” Nursing 32(10):104, October 2002. Used with permission.
In the operating room, surgical openings should be kept lower than the
level of the heart.
Tell scuba divers that they should obtain appropriate training.
Air is introduced into the circulation.
The air embolism obstructs blood flow through the vessels.
The blood supply is diminished or cut off, and tissues are starved of
oxygen, causing them to die.
The effect of the air embolism depends on the part of the body to which
the vessel supplies blood.
Air emboli are most common:
– during surgery (craniotomies, head and neck surgeries, vaginal deliveries, cesarean deliveries, spinal instrumentation procedures, and liver
– during CV line insertions
– after accidental introduction of air into the circulation during
– during scuba diving
– following penetrating wounds.
Angina is severe pain in the chest that’s typically described as “heaviness,” “crushing,” or “tightening.” The pain may radiate to the arms or
jaw. It occurs when oxygen demands of the heart exceed the oxygen supply to the heart muscle.
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➤ UNDERSTANDING CHEST PAIN
Use this table to accurately assess chest pain.
Signs and symptoms
Aching, squeezing, pressure, heaviness, burning pain; usually subsides within 10 minutes
Tightness or pressure; burning, aching pain, possibly accompanied
by shortness of breath, diaphoresis, weakness, anxiety, or nausea;
sudden onset; lasts 30 minutes to 2 hours
Sharp and continuous; may be accompanied by friction rub; sudden
Excruciating, tearing pain; may be accompanied by blood pressure
difference between right and left arm; sudden onset
Sudden, stabbing pain; may be accompanied by cyanosis, dyspnea,
or cough with hemoptysis
Sudden and severe pain; sometimes accompanied by dyspnea, increased pulse rate, decreased breath sounds, or deviated trachea
Angina occurs in four major forms:
Stable. The pain in this type of angina is predictable in frequency and
duration; it can be relieved with nitrates and rest.
Unstable. This pain is more intense and is easily induced. It lasts longer
and occurs more frequently than stable angina. Unstable angina is also
called pre-infarction angina and is classified as an acute coronary syndrome, along with a myocardial infarction (MI).
Prinzmetal’s or variant angina. The pain in Prinzmetal’s angina results
from unpredictable coronary artery spasm.
Microvascular. This is an angina-like chest pain caused by impaired vasodilator reserve in a patient with normal coronary arteries.
ALERT In patients with coronary artery disease (CAD), angina of
increasing frequency, severity, or duration (especially if not provoked by exertion, a heavy meal, or cold and wind) may signal an
Assess the rate, depth, pattern, and quality of respirations.
Assess the patient’s level of consciousness.
430702.qxd 3/17/05 3:53 AM Page 15
Substernal; may radiate to
jaw, neck, arms, and back
Eating, physical effort,
smoking, cold weather,
stress, anger, hunger, lying
Rest, nitroglycerin (Note:
Unstable angina appears
even at rest.)
Typically across chest, but
may radiate to jaw, neck,
arms, or back
Opioid analgesics such as
Substernal; may radiate to
neck or left arm
Deep breathing, supine
Sitting up, leaning forward,
Retrosternal, upper abdominal, or epigastric; may radiate to back, neck, or shoulders
Over lung area
Analgesics, chest tube
Obtain the patient’s vital signs and monitor blood pressure and heart
Ask the patient to describe the pain in detail, including its sensation, location, radiation, duration, and precipitating and alleviating factors.
(See Understanding chest pain.)
Assess for associated symptoms, such as dyspnea, tachycardia, palpitations, nausea, vomiting, fatigue, diaphoresis, pallor, weakness, syncope,
Provide supplemental oxygen and prepare the patient for intubation
and mechanical ventilation, if necessary.
Assist the patient to bed.
Initiate continuous cardiac monitoring and obtain a 12-lead electrocardiogram and portable chest X-ray.
Administer aspirin (to prevent platelet aggregation), nitrates (to vasodilate and to reduce pain), morphine (to reduce pain and provide sedation), and beta-adrenergic blockers (to reduce pain), as ordered.