CARE OF CLIENT IN ACUTE BIOLOGIC CRISIS

DEFINITION
Emergency Management – refers to care given to patients with urgent and critical
needs. However, because many people lack access to health care, the emergency
department is increasingly used for non-urgent problems. Therefore, the
philosophy of emergency management has broadened to include the concept that
an emergency is whatever the patient or the family considers it to be.
Scope and Practice of Emergency Nursing
 The emergency nurse has had specialized education, training, experience,
and expertise in assessing and identifying patient’s health care problems in
crisis situations.
 The emergency nurse establishes priorities, monitors and continuously
assesses acutely ill and injured patients, supports and attends to families,
supervises allied health personnel, and teaches patients and families within a
time-limited, high-pressured care environment
 Nursing interventions are accomplished interdependently, in consultation
with or under the direction of a physician or nurse practitioner. The strengths
of medicine and nursing are complementary in an emergency situation.
Appropriate nursing and medical interventions are anticipated based on
assessment data. The emergency health care staff members work as a team
in performing the highly technical hands-on skills required to care for
patients in emergency situations.
Patients in the ER have a wide variety of actual or potential problems, and their
condition may change constantly. Therefore, nursing assessment must be
continuous, and nursing diagnoses change with the patient’s condition.
 Although a patient may have several diagnoses at a given time, the focus is
on the most life-threatening ones; often both independent and interdependent
nursing interventions are required.
Issues in Emergency Nursing Care
1. Documentation of Consent and Privacy
2. Limiting Exposure to Health Risks
3. Violence in the Emergency Department
a. Safety is the first priority. Protection of the department provides
protection for the patients, families, and staff.
b. Metal detectors, silent alarm systems, and secured entry into the
department assists in maintaining safety.
c. Members of gangs and feuding families need to be separated in the ER,
waiting room and later in the ward to avoid angry confrontations
d. Security personnel should be ready to assist at all times. The ER should be
able to be locked against entry if security is at all in question.
 Issues in Emergency Nursing Care
e. Patients from prison and those who are under guard need to be handcuffed to the
bed and appropriately assessed to ensure the safety of the hospital staff and other
patients.
e.1. never release the hand or ankle restraint (handcuff)
e.2. always have a guard present in the room.
e.3 place the patient face down on the stretcher to avoid injury from head-butting,
spitting, or biting.
e.4 use restraints on any violent patient as needed.
e.5. administer medication if necessary to control violent behavior until definitive
treatment can be obtained.
f. In the case of gunfire in the ER, self-protection is a priority. There is no
advantage to protecting others if the caregivers are also injured. Security officers
and police must gain control of the situation first, and then care is provided to the
others.
Issues in Emergency Nursing Care
4. Providing Holistic Care
a. patient-focused interventions
 the unconscious patient should be treated as if conscious; that is, the patient
should be touched, called by name, and given an explanation of every
procedure that is performed.
b. Family-focused interventions
 The family is kept informed about where the patient is, how he/she is doing,
and the care that is being given. Allowing the family to stay with the patient,
when possible also helps allay their anxieties.
Guidelines in Helping Family Members Cope with Sudden Death
1. Take the family to a private place.
2. Talk to the family together, so that they can mourn together. 3. Reassure the
family that everything possible was done; inform them of the treatment rendered.
4. Avoid using euphemisms such as “passed on”. Show the family that you care by
touching, offering coffee, water, and the services of the chaplain.
5. Encourage family members to support each other and to express emotions
freely (grief, loss, anger, helplessness, tears, disbelief).
6. Avoid giving sedation to family members; this may mask or delay the grieving
process, which is necessary to achieve emotional equilibrium and to prevent
prolonged depression.
7. Encourage the family to view the body if they wish; this action helps to integrate
the loss. Cover disfigured and injured areas before the family sees the body. Go
with the family to see the body. Show acceptance by touching the body to give the
family “permission” to touch.
8. Spend time with the family members to talk about the deceased and what he/she
meant to them; this permits ventilation of feelings of loss. Encourage the family to
talk about events preceding admission to the ER. Do not challenge initial feelings
of anger and denial.
9. Avoid volunteering unnecessary information (e.g., the patient was drinking)
Principles of Emergency Care
 By definition, emergency care is care that must be rendered without delay.
In an ER, several patients with diverse health problems-some life
threatening, some not – may present to the ED simultaneously. One of the
first principles of emergency care is triage.
TRIAGE – comes from the French word “ trier”, meaning “ to sort”. In the
daily routine of the ER, triage is used to sort patients into groups based on the
severity of their health problems and the immediacy with which these problems
must be treated.
Triage Systems
Categories
1. Emergent – patients have the highest priority – their conditions are life-
threatening and they must be seen immediately.
2. Urgent – patients have serious health problems but not immediately life-
threatening ones; they must be seen within 1 hour.
3. Nonurgent – patients have episodic illnesses that can be addressed within 24
hours without increased morbidity.
4. Fast Track – patients require simple first aid or basic primary care and may be
treated in the ER or safely referred to a clinic or physician’s office
Triage Systems
Levels
1. Resuscitation – patients need treatment immediately to prevent death.
2. Emergent - patients may deteriorate rapidly and develop a major life threatening
situation or require time-sensitive treatment.
3. Urgent – Patients have non-life threatening conditions but require two or more
resources to provide their care. If the patients’ vital signs deviate significantly from
their baseline, they may require “up-triaging” to the emergent category.
4. Nonurgent- patients have non-life threatening conditions and likely need only
one resource to provide for their needs.
5. Minor category – patients have no life-threatening conditions and likely require
no resources to provide their evaluation and management.
 Resources are defined as imaging studies, medications administered IV or
IM routes, and invasive procedures. Insertion of an indwelling catheter is an
example of a one-resource procedure. Moderate sedation would be classified
 as a two-resource procedure because this requires frequent monitoring and
IV medications.
QUESTIONS - ER
The following questions reflect the minimum information that should be
obtained from the patient or from the person who accompanied the patient to
the ER:
1. What were the circumstances, precipitating events, location and time of the
injury or illness?
2. When did the symptoms appear?
3. Was the patient unconscious after the injury or onset of illness?
4. How did the patient get to the ER?
5. What was the health status of the patient before the injury or illness?
6. Is there a history of medical illness or previous surgeries? A history of
admissions to the hospital?
7. Is the patient currently taking any medications, especially hormones, insulin,
digitalis or anticoagulants?
8. Does the patient have any allergies, especially to eggs, latex, medications, or
nuts?
9. Does the patient have any fears? Does the patient feel that he or she is in a
situation in which he/she is unsafe?
10. When was the last meal eaten?
11. When was the LMP?
12. Is the patient under a physician’s care? What are the name and location of the
physician?
13. What was the date of the patent’s most recent tetanus immunization?
Assess and Intervene
 A systematic approach to effectively establish and treat health priorities is
the primary / secondary approach. The primary survey focuses on stabilizing
life-threatening conditions. The ER staff work collaboratively and follow the
ABCD (airway, breathing, circulation, disability method:
1. Establish a patent airway.
2. Provide adequate ventilation, employing resuscitation measures when
necessary. (trauma patients must have the cervical spine protected and chest
injuries assessed first).
3. Evaluate and restore cardiac output by controlling hemorrhage, preventing
and treating shock, and maintaining or restoring effective circulation. This
includes the prevention and management of hypothermia.
4. Determine neurologic disability by assessing neurologic function using
the Glasgow Coma Scale.
Secondary Survey
  After these priorities have been addressed, the ER team proceeds with the
secondary survey. This includes the following
1. A complete health history and head-to-toe assessment </li></ul><ul><li>
2. Diagnostic and laboratory testing
3.Insertion or application of monitoring devices such as ECG electrodes,
arterial lines, or urinary catheters.
4. Splinting of suspected fractures
5. Cleansing, closure, and dressing of wounds
6. Performance of other necessary interventions based on the patient’s
condition.
SHOCK
 Is a syndrome in which the circulation or perfusion of blood is inadequate to
meet tissue metabolic demands. Cellular anoxia will ensue and lead to tissue
death unless the process is reversed.
 During shock, the body struggles to survive, calling on all its homeostatic
mechanism to restore blood flow </li></ul>
Classifications of Shock
1. Hypovolemic shock – refers to a state in which the volume contained within the
intravascular compartment is inadequate for perfusion of body tissue. There is
usually a 15%-25% reduction of intravascular volume.
e.g., hemorrhagic shock – loss of whole blood about 1/3 of his normal blood
volume
2. Cardiogenic shock – which occurs when the heart has an impaired pumping
ability; it may be of coronary or noncoronary event origin.
3. Septic shock- which is caused by an infection
4. Neurogenic shock- which is caused by alterations in vascular smooth muscle
tone, caused by either nervous system injury or complications associated with
medications such as epidural anesthesia.
5. Anaphylactic shock – which is caused by hypersensitivity reaction.

Stages of Shock
 Compensatory stage
-BP remains normal.
-Vasoconstriction , increased HR, and increased contractility of the heart
-stimulation of the SNS and subsequent release of cathecolamines.
-The body shunts blood from organs to the brain and heart
Compensatory Mechanism in Shock
Initial physiologic insult to shock state

Decrease in CO and tissue perfusion

SNS activation

Endocrine response

RAA activation

Vasoconstriction and activation of ADH - ↑ Preload

↑ BP, HR, and Myocardial contractility Renal system conserves Na and H2O -↑ Preload

↑ vascular compliance, blood volume and CO

Restoration of tissue perfusion

Medical Management
1. identifying the cause of the shock, correcting the underlying disorder so that
shock does not progress, and supporting those physiologic processes that thus far
have responded successfully to threat.
2. Fluid replacement and medication therapy must be initiated to maintain an
adequate BP and reestablish and maintain adequate tissue perfusion.
Nursing Management
1. Monitoring Tissue Perfusion
a. assess the patient at risk for shock systematically to recognize the subtle
clinical manifestations of the compensatory stage before the patient’s BP
drops
b. Observe for changes in LOC, VS, urinary output, skin and laboratory
values
c. Administer prescribed fluids and medications.
2. Reducing anxiety
 a. provide brief explanations about the diagnostic and treatment procedures
b. Speaking in a calm, reassuring voice and using gentle touch also help ease
the patient’s concerns.
3. Promoting safety </li></ul>
2. Progressive Stage
-the mechanisms that regulate BP can no longer compensate
-MAP (mean arterial pressure) falls below normal limits.
-Patients are clinically hypotensive; this is defined as a SBP of <90mmHg or a
decrease in SBP of 40mmHg.
Assessment and Diagnostic Findings
1. Respiratory Effects
-decompensation of the lungs increases the likelihood that mechanical
ventilation will be needed.
-Respirations are rapid and shallow; crackles are heard over the lung fields.
-Decreased pulmonary blood flow causes arteriolar O2 levels to decrease and
CO2 levels to increase.
-The hypoperfused alveoli stop producing surfactant and subsequently collapse.
-Pulmonary capillaries begin to leak, spilling their contents, thus causing
pulmonary edema, diffusion abnormalities (shunting), and additional alveolar
collapse.
Assessment and Diagnostic Findings
2. Cardiovascular Effect - ischemia and dysrhythmia due to lack of adequate
blood supply, the HR is rapid, sometimes exceeding 150 bpm. The patient may
complain of chest pain and even suffer a myocardial infarction.
 Levels of cardiac enzymes increase.
 myocardial depression and ventricular dilation may further impair the heart’s
ability to pump enough blood to the tissues to meet oxygen requirements.
3. Neurologic Effects- mental status deteriorates and occur with decreased
tissue perfusion and hypoxia. Initially, patient may exhibit a subtle change in
behavior or agitation and confusion. Subsequently, lethargy increases, and the
patient begins to lose consciousness.
Assessment and Diagnostic Findings
 Hepatic effects – decreased blood flow to the liver impairs the ability of the
liver cells to perform metabolic and phagocytic functions. The patient is less
able to metabolize medications and metabolic waste products, such as
ammonia and lactic acid.
 Metabolic activities of the liver (gluconeogenesis and glycogenolysis) are
impaired. The patients become more susceptible to infection as the liver fails
to filter bacteria from the blood.
  Liver enzymes and bilirubin levels are elevated and the patient appears
jaundiced. </li></ul><ul><ul><li>4. Renal Effects – GFR decreases. ARF
may develop (increased BUN, crea), fluid and electrolytes shift, acid-base
imbalances and a loss of renal-hormonal regulation of BP. </li></ul></ul>
Assessment and Diagnostic Findings
5. GI effects – can cause stress ulcers in the stomach, putting the patient at risk for
GI bleeding. In the small intestine, the mucosa can become necrotic and slough off,
causing bloody diarrhea.
6. Hematologic Effects – the combination of hypotension, sluggish blood flow,
metabolic acidosis, coagulation system imbalance, and generalized hypoxemia can
interfere with normal hemostatic mechanism.

Medical Management
 Will depend on the specific type of shock and its underlying cause. It also
depends on the degree of decompensation in the organ system
1. optimizing intravascular volume
2. supporting the pumping action of the heart
3. improving the competence of the vascular system
4. supporting the respiratory system
5.Early enteral nutritional support, aggressive hyperglycemic control with IV
insulin and use of antacids, H2 receptor blockers or antipeptic agents to reduce
the risk of GI ulceration and bleeding.
Nursing Management
1) Preventing complications
a) monitor the patient for early signs of complications. It includes evaluating
blood levels of medications, observing invasive vascular lines for signs of
infection, and checking neurovascular status if arterial lines are inserted.
b) frequent oral care, aseptic suction technique, turning, and elevating the head
of the bed to prevent aspiration.
c) positioning and repositioning of the patient to promote comfort and maintain
skin integrity.
2) Promoting Rest and comfort to minimize the cardiac workload.
3) Supporting family members

3. Irreversible (refractory) Stage – represents the point along the shock

continuum at which organ damage is so severe that the patient does not respond
to treatment and cannot survive
Medical Management:
  Is usually the same as for the progressive stage. Strategies that may be
experimental may be tried to reduce or reverse the severity of shock.
</li></ul>
Nursing Management
i. carry out prescribed treatments, monitoring the patient, preventing
complications, protecting the patient from injury, and providing comfort.
ii. Offer brief explanations to the patient about what is happening is essential
even if there is no certainty that the patient hears or understands what is
being said.
iii. Simple comfort measures, including reassuring touches, should continue to
be provided despite the patient’s
iv. As it becomes obvious that the patient is unlikely to survive, the family must
be informed about the prognosis and likely outcome.
v. Opportunities should be provided, throughout the patient’s care, for the
family to see, touch, and talk to the patient.
vi. Close family friends or spiritual advisors may be of comfort to the family
members in dealing with the inevitable death of their loved one.
Overall Management Strategies in Shock
 Fluid replacement to restore intravascular tone
-Crystalloid
NSS
LRs
-Colloid Solutions
Dextran
Overall Management Strategies in Shock
Complications of Fluid Administration
o The most common and serious side effects of fluid replacement are
cardiovascular overload and pulmonary edema .
o Management:
1. Monitor frequently the urine output, changes in mental status, skin
perfusion, and changes in vital signs.
2. Lung sounds are auscultated frequently to detect signs fluid accumulation.
Adventitious lung sounds, such as crackles may indicate pulmonary edema.
3. A CVP may be inserted to monitor the patient’s response to fluid
replacement
4. Vasoactive medications to restore vasomotor tone and improve cardiac
function.
5. Nutritional support to address the metabolic requirements that are often
dramatically increased in shock. Patient in shock may require 3000 calories
 daily. The release of catecholamines early in shock continuum causes
depletion of glycogen stores in about 8-10 hours.

HYPOVOLEMIC SHOCK
 Is the most common type of shock and is characterized by a decreased
intravascular volume. Body fluids is contained in intracellular and
extracellular compartments. Intracellular fluids account for about 2/3 of the
total body water. Hypovolemic shock occurs when there is a reduction in
intracellular volume by 15%-25%, which represents a loss of 750 – 1300 ml
of blood in a 70-kg person.
Risk Factors for Hypovolemic Shock
A. External: Fluid Losses B. Internal: Fluid Shifts
1. Trauma 1. Hemorrhage
2. Surgery 2. Burns
3. Vomiting 3. Ascites
4. Diarrhea 4. Peritonitis
5. Diuresis 5. Dehydration
6. Diabetes Insipidus

Medical Management
Goals:
1. restore intravascular volume to reverse the sequence of events leading to
inadequate tissue perfusion
2. redistribute fluid volume
3. correct the underlying cause of the fluid loss as quickly as possible.
Hypovolemic Shock Interventions:
1. Treatment of the underlying cause
a. If hemorrhaging, applying pressure to the bleeding site or surgery to stop
bleeding.
b. If due to diarrhea or vomiting, medications to treat diarrhea and vomiting are
administered while efforts are made to identify and treat the cause
2. Fluid and Blood replacement
3. Redistribution of fluid
4. Pharmacologic therapy
Nursing Management
1. Administering blood and Fluid safely
2. Implementing other measures
a. oxygen is administered to increase the amount of oxygen carried by available
hemoglobin in the blood.
b. The nurse must direct efforts to the safety and comfort of the patient.
CARDIOGENIC SHOCK
o Occurs when the heart’s ability to contract and to pump blood is impaired
and the supply of oxygen is inadequate for the heart and tissues
Types:
1. Coronary cardiogenic shock – occurs when a significant amount of the
left ventricular myocardium has been damaged.
2. Noncoronary cardiogenic shock – are related to conditions that stress the
myocardium (e.g., severe hypoxemia, acidosis, hypoglycemia,
hypocalcemia, and tension pneumothorax) as well as conditions that result
in ineffective myocardial function (e.g., cardiomyopathies, valvular
damage, cardiac tamponade, dysrhythmias)

Pathophysiology
Decreased cardiac contractility

Decreased stroke volume and cardiac output

Pulmonary congestion Decreased systemic tissue perfusion decreased coronary artery

Perfusion

Clinical Manifestations: Patients in cardiogenic shock may experience the pain of

angina and develop dysrhythmias and hemodynamic instability.

Medical Management
1. Correction of underlying cause
a. In the case of coronary cardiogenic shock, the patient may require thrombolytic
therapy, angioplasty, CABG, intra-aortic balloon pump therapy, or some
combination of these treatments. b. In the case of noncoronary cardiogenic shock,
interventions focus on correcting the underlying cause, such as replacement of a
faulty cardiac valve, correction of dysrhythmias, correction of acidosis and
electrolyte disturbances, or treatment of the tension pneumothorax.
2. Initiation of First-Line treatment
a) supplying supplemental oxygen
b) controlling chest pain
c) providing selected fluid support
d) administering vasoactive medications
e) controlling HR with medication or by implementation of a transthoracic IV
pacemaker.
3. Oxygenation via nasal cannula at 2-6 lpm
4. Pain control – IV morphine sulfate.
5. Laboratory marker monitoring (cardiac enzymes) </li></ul>
Nursing Management
1. Preventing cardiogenic shock
a. conserve patient’s energy
b. restore adequate cardiac function and tissue perfusion
2. Monitoring hemodynamic status:
a. arterial lines
b. ECG
c. Cardiac, pulmonary and laboratory values
3. Administering medications and IV Fluids
4. Maintaining Intra-aortic balloon counterpulsation
5. Enhancing safety and comfort

CIRCULATORY SHOCK
 Occurs when blood volume is abnormally displaced in the vasculature (e.g.,
when blood pools in peripheral blood vessels). Circulatory shock can be
caused either by a loss of sympathetic tone or by release of biochemical
mediators from cells.
Classifications:
 Septic shock
 Neurogenic shock
 Anaphylactic shock </li></ul>

Pathophysiology
Precipitating event

Vasodilation

Activation of inflammatory response

Misdistribution of blood volume

Decreased venous return

Decreased cardiac output

Decreased tissue perfusion

Risk Factors for Circulatory Shock
1. Septic Shock
a. Immunosuppression
b. Extremes of age (< 1 yr and > 65 yr)
c. Malnourishment
d. Chronic illness
e. Invasive procedures
2. Neurogenic Shock
a. Spinal cord injury
b. Spinal anesthesia
c. Depressant action of medications
d. Glucose deficiency
3. Anaphylactic Shock
a. Penicillin sensitivity
b. Transfusion reaction
c. Bee sting allergy
d. Latex sensitivity
e. Severe allergy to some foods or medications

Septic Shock: shock associated with sepsis; characterized by symptoms of sepsis

plus hypotension and hypoperfusion despite adequate fluid volume replacement
Medical Management:
1. Identification of the cause of infection. Specimens of blood, sputum, urine,
wound drainage, and tips of invasive catheters are collected for culture using
aseptic technique.
2. Any potential source must be eliminated. IV lines are removed and reinserted at
other body sites. Antibiotic-coated IV central lines may be inserted to decrease the
risk of invasive line-related bacteremia in high risk patients, such as elderly.
3. Fluid replacement must be instituted to correct the hypovolemia that results from
incompetent vasculature and the inflammatory response.
4. Pharmacologic therapy.
5. Nutritional therapy
Nursing Management
1. All invasive procedures must be carried out with aseptic technique.
2. Monitor patient for signs of infection.
3. Administer prescribed IV fluids and medications, including antibiotic agents and
vasoactive medications to restore vascular volume.
4. Laboratory values must be monitored.
5. Monitor hemodynamic status
Neurogenic Shock
 vasodilation occurs as a result of a loss of balance between parasympathetic
and sympathetic stimulation. The patient experiences a predominant
parasympathetic stimulation that causes vasodilation lasting for an extended
period leading to a relative hypovolemic state.
 However, blood volume is adequate, because the vasculature is dilated; the
blood volume is displaced, producing hypotensive state resulting to a drastic
decrease in the patient’s systemic vascular resistance and bradycardia.
Inadequate BP results in the insufficient perfusion of tissues and cells.
Causes:
1. Spinal cord injury, spinal anesthesia, or nervous system damage.
2. Depressant effect of medications or from lack of glucose.

Medical Management
1. restoring sympathetic tone, either through stabilization of a spinal cord injury or,
in the instance of spinal anesthesia, by positioning the patient properly.
2. If hypoglycemia is the cause, glucose is rapidly administered

Nursing Management
1. Elevate and maintain the head of the bed elevated at least 30 degrees to prevent
neurogenic shock when a patient receives spinal or epidural anesthesia. Elevation
of the head helps prevent the spread of the anesthetic agent up to the spinal cord.
2. In suspected spinal cord injury, neurogenic shock may be prevented by carefully
immobilizing the patient to prevent further damage to the spinal cord.
3. Support CV and neurologic function until the usually transient episode of
neurogenic shock resolves. Applying elastic compression stockings and elevating
the foot of the bed may minimize the pooling of blood in the legs
4. Administration of heparin or LMWH (Lovenox) as prescribed, application of
elastic compression stockings, or use of pneumatic compression of the legs may
prevent thrombus formation
5. Passive ROM of the immobile extremities helps promote circulation.
Anaphylactic Shock
 occurs rapidly and is life-threatening. Because anaphylactic shock occurs in
patients already exposed to an antigen and who have developed antibodies to
it, it can often be prevented
 It is caused by a severe allergic reaction when patients who have already
produced antibodies to a foreign substance (antigen) develop a systemic
antigen-antibody reaction.
Medical Management
1. removal of the causative antigen
2. Epinephrine is given for its vasoconstrictive effect.
3. Diphenhydramine (Benadryl) is administered to reverse the effects of histamine,
thereby reducing capillary permeability.
4. Nebulized medications such as albuterol (Proventil), may be given to reverse
histamine-induced bronchospasm.
5. If cardiac and respiratory arrests are imminent or have occurred, CPR is
performed. Endotracheal intubation or tracheotomy may be necessary to establish
an airway.
6. IV lines are inserted to provide access for administering fluids and medications.
Nursing Management:
a) assess patient for allergies or previous reactions to antigens (e.g.,
medications, blood products, foods, contrast agents, latex) and communicate
the existence of allergies or reactions to others.

Immediate Life-Saving Interventions

A B

Life-saving airway/breathing intubation, BMV ventilation, surgical airway,

intervention emergent CPAP or BiPAP

Life-saving electrical therapy defibrillation, emergent cardioversion, external

intervention pacing

Life-saving procedures chest needle decompression, pericardiocentesis,

intervention open thoacotomy, IO

Life-saving hemodynamics significant IV fluid resuscitation, blood

intervention administration, control of major bleeding

Life-saving medications naloxone, D50, dopamine, atropine, adenocard

intervention

NOT a life-saving intervention for oxygen administration via nasal cannula or non-
airway/breathing rebreather

NOT a life-saving procedural ECG, labs, ultrasound, diagnostic tests

intervention

NOT a life-saving hemodynamic IV access, saline lock for meds

intervention

NOT a life-saving electrical cardiac monitoring

therapy intervention

NOT a life-saving medication ASA, IV nitroglycerine, antibiotics, heparin, pain

meds, respiratory treatments with beta agonists