Скачати 84.84 Kb.
Зміст1. Topic: FOREIGN BODIES OF THE SOFT TISSUES, RESPIRATORY TRACT AND ESOPHAGUS. THE MAIN NOTIONS OF CLINICAL AND BIOLOGICAL DEATH
2. Duration of the class: 4 academic hour.
3.2. The student should be able
3.3. The student should master practical skills
Principles of Emergency Care
Assessing the Person in Emergencies
A: Airway and Cervical Spine
C: Circulation and Bleeding
Observe the Pulse.
Assess for Shock.
Basic Cardiac Life Support
Activate the Emergency Medical Services System
Position the Person
Open the Airway
BUKOVINIAN STATE Medical university
DEPARTMENT OF PATIENTS CARE AND
HIGHER NURSE EDUCATION
on the methodical conference of department
of patients’ care and higher
“ ” ________ 200_ protocol N __
Chief of department, associate professor I.A. Plesh
FOR SELF-PREPARATION OF STUDENTS
TO PRACTICAL CLASS №26-27
FOREIGN BODIES OF THE SOFT TISSUES, RESPIRATORY TRACT AND ESOPHAGUS. THE MAIN NOTIONS OF CLINICAL AND BIOLOGICAL DEATH. RESUSCITATION.
nursing in surgery
for 3nd year students
of medical faculty №4,
specialty "nurse business''
Methodical instruction was prepared by:
Assistant Riabyi S.I.
Chernivtsi - 2010
(the main notions of the foreign bodies of soft tissues, respiratory tract and esophagus. Nurse’s tactics in case of the foreign bodies. The main notions of clinical and biological death. Indications to resuscitation. The technique of closed cardiac massage and artificial lungs ventilation. Efficacy of methods of resuscitation).
3. Study aim:
3.1. The student should know:
·4. Advice for students:
Thousands of people lose their lives in accidents every year. A high percentage of accidents are motor vehicle accidents (MVA), but the occurrence of gunshot wounds is also on the rise. Most accidents are preventable. Trauma refers to a wound or injury and usually is caused by a force outside the person. This chapter describes the actions a first aid person should take in the event of trauma. Although anyone can assist at the scene of an accident, the text assumes the nurse is present.
Simply because you are a nurse, people expect you to be able to deal with emergencies. It is important that you be fully able to meet this expectation. Basic emergency care principles tell you what to do and what not to do when accidents happen. In a serious emergency, you must decide quickly what you are going to do. A confident, matter-of-fact manner will reassure the victim and onlookers. If you appear to be confident, others will follow your instructions and assist you.
If brain cells do not have an oxygenated blood supply, they begin to die within 4 to 6 minutes. Therefore, it is vital for a person giving emergency care in a life-threatening situation to act quickly. Because the stress level is high at the scene of an emergency, it is helpful to have a plan of action and a predetermined, orderly method of assessment and care.
Make sure the scene is safe before rushing to assist in an emergency. Check the environment and look for clues. Is there danger of fire or explosion? Is there danger of being in the lane of traffic? Are there electrical hazards? Live wires? If the scene is unsafe, you need to call for help before assisting the person. Yc may also need to move the person away from danger before you can begin your first aid care. The person, however, should not be moved if the area is safe.
Primary assessments are made as soon as you arrive the scene. During this assessment you discover an deal with life-threatening problems or injuries. Unless there are life-threatening problems to correct, the primary survey usually can be completed in 60 seconds.
The secondary assessment involves taking and recording vital signs and continues with a head-to-toe assessment. This assessment should take from 1 to 2 minutes, unless injuries are found that require immediate intervention. If the person has life-threatening problems, the secondary assessment may be delayed until the person is being transported.
Use the letters A, B, C, D, and E to help you remember the order for assessing the person in an emerger situation.
A = Airway and cervical spine
B = Breathing
C = Circulation and bleeding
D = Disability
E = Expose and examine
The patency of the airway is evaluated to determine whether or not the airway is open (patent). As this is done, keep in mind the mechanism, location, and scope of the injury. If there is a possibility of a spinal injury, consider stabilizing the person's cervical spine before attempting other activities. If the trauma patient is not breathing, open the airway, using the jaw thrust maneuver (see Chapter 32). This technique opens the airway, but does not extend the neck. If the emergency does not involve trauma, it is appropriate to use the head tilt-chin lift method to open the airway (see Chapter 32). After opening the airway, quickly clear any visible foreign material from the mouth.
The most common airway obstruction in an unconscious person is caused by the tongue falling back and occluding the airway.
Assess breathing by listening for breath sounds, by watching for movements of the chest, and by feeling for breath against your cheek and ear. If breathing is not present, pinch the person's nose and give the person two slow mask-to-mouth breaths. Each breath should be of sufficient force to cause the chest to rise and should take from 1.5 to 2 seconds to deliver. Allow the client to exhale passively between breaths.
If you are unable to ventilate the person on your first attempt, reposition the airway and try again. If you are still unable to ventilate the person, the airway is obstructed. Use the obstructed-airway technique to remove the obstruction and establish the airway. (See Chapter 32 for a description of these techniques in more detail.)
Mouth-to-mouth breathing is not usually used. Mask-to-mouth breathing is the current method.
Maintain the Airway. It is important to maintain the airway even if breathing is present. Blood, body fluids, and vomitus may accumulate in the mouth and should be removed. Be sure the person's tongue is out of the way. (The tongue can occlude the airway in even such a minor event as fainting.) Position the person on the side if vomiting occurs.
^ As you assess breathing, note if the respirations appear to be at normal rate and depth. Examine the person's mouth, gums, lips, and nail beds for color and moisture. Blueness (cyanosis) indicates a lack of oxygen.
Look for Life-Threatening Chest Injuries. If indicated by the mechanism of injury, examine the chest for life-threatening injuries. Care for these injuries immediately if they are present. Examples include a puncture wound of the chest.
Palpate the Pulse. Palpate the pulse for 5 to 10 seconds. If there is no pulse, ask bystanders to call for assistance. The person needs advanced life support as soon as possible. Begin cardiac compressions and rescue breathing. (Chapter 32 contains a description of these procedures.)
^ If pulse is present, note its rate and regularity. Does it seem normal? Do not count the pulse at this time; just try to get a sense of its quality. As you palpate the pulse, also observe skin color, temperature, and neck veins.
Reassess Breathing. A person may have a heartbeat without having respirations; therefore, you must reassess breathing. Rescue breathing must be performed if breathing is not present.
^ The nurse should consider the possibility of shock in any injury. Severe blood loss usually causes shock. The treatment of shock is discussed above. Use the capillary refill test to evaluate for shock, as follows:
Assess for Hemorrhage. The presence of a palpable pulse indicates that the person's heart is beating. However, you must also assess for major bleeding (hemorrhage).
Stop Bleeding. Hemorrhage must be controlled immediately or the person will die from blood loss. With your gloved hands, place sterile compresses over wounds and apply pressure. If blood seeps through the compresses, do not remove old dressings but place additional compresses over the top of the compress already in place. You may need to apply additional pressure over the wound.
Measures that can be used to stop bleeding include:
Sudden Death and Life Support
Sudden death takes place any time breathing and the heartbeat stop abruptly or unexpectedly. Causes of sudden death may include the following:
There are two definitions for death: clinical and biologic. Clinical death occurs when breathing and the heartbeat stop. This type of sudden death may be reversible with prompt action by people trained in basic and advanced life support; a person often can be resuscitated. The term biologic death refers to permanent damage of brain cells due to lack of oxygen. Biologic death is final.
Basic life support, also called basic cardiac life support (BCLS), includes rapid entry into the emergency medical services (EMS) system, performance of CPR, and use of techniques to clear an obstructed airway.
CPR is a technique that artificially supports circulation and ventilation (breathing) in a victim of cardiopulmonary arrest. It helps to provide oxygen to the brain, heart, lungs, and other organs until advanced life support can be given.
CPR must be performed immediately after cardiac and respiratory arrest. If CPR is not begun immediately, sudden death will result in biologic death. The American Heart Association and the American Red Cross have established guidelines for CPR. Changes are made in CPR guidelines as new medical and emergency techniques are developed. Healthcare workers are expected to keep abreast of the latest techniques. Basic techniques are described in this chapter.
A one-way filtered breathing mask should be used for CPR, whenever possible, to protect the rescuer.
Advanced Cardiac Life Support
Emergency medical technicians, paramedics, and many nurses are trained in advanced cardiac life support
(ACLS) techniques. Advanced cardiac life support includes starting intravenous lines, administering fluids and drugs, using defibrillation and cardiac monitoring, administering drug therapy and oxygen, and opening and maintaining the airway (sometimes by inserting a tube into the person's trachea, which is called intubation).
The nurse or professional rescue person will work under the supervision of a physician at the scene or will have standing orders previously established by a physician. If you do not have such orders, you must function as a lay rescuer or first aid person at the scene of an accident or sudden death.
Emergencies create high anxiety levels. The person giving CPR must remain calm and remember the steps. One method used to recall the steps in BLS is referred to as the ABCs of BLS. Each phrase begins with an assessment of the person's response. If the person does not respond, steps are continued. The phases are as follows:
* A Airway
* B Breathing
* C Circulation
The following discussion of the one-rescuer method of CPR uses the method for adults and children older than 8 years. The techniques for CPR differ somewhat in infants and young children. Infants and children are discussed later in this chapter. Although this section is broken up into the ABCs and several skills and procedures, when CPR actually is performed, everything flows together.
To establish unresponsiveness, shake the person's shoulder and shout, "Are you okay?" If the person does not respond, continue in the steps.
Activate the EMS system immediately after unresponsiveness is determined. The number to call in most communities is 911. The person who calls should have basic information related to exact location, what happened, how many people need help, the person's condition, and what kind of aid is being given.
If the injured person may have sustained a back or \ neck injury, he or she must not be moved until help comes. In other situations, the person must be supine! on a hard surface if you are to perform CPR. If the per-' son is lying face down, the person performing CPR (called the rescuer) rolls the person over as a unit (head, shoulders, and torso rolling simultaneously). The rescuer should be at the person's side.
The Jaw-Thrust Method. If the nurse has reason to believe that there may be a neck injury, the jaw-thrust method should be used to open the airway. This is done by positioning the hands at the angles of the person's jaw. The jaw is displaced forward while tilting the head backward. This usually can be accomplished without extending the neck. The head should be supported without moving it from side to side.
-If ventilation is unsuccessful in this case, tilt the head back slightly. This should open the airway and effect ventilation.
^ If there is no evidence of head or neck trauma, the nurse opens the airway by way of the head-tilt chin lift. The rescuer's hand closest to the person's head is placed on the person's forehead, pressing back and down. The fingers of the other hand are placed under the bony part of the patient's chin to lift it up, while pushing back and down with the top hand. This method makes the mouth-to-mouth seal easier to maintain for CPR.
The tongue is the most common cause of obstructed airway in an unconscious victim. In many cases all that is needed is to open the patient's airway to restore breathing.
The Finger Sweep. Any foreign matter, vomitus, or liquids should be removed from the person's airway before resuscitation can begin. In many cases removing the foreign body will restore breathing. If a foreign body can be seen in the mouth, it should be removed with the fingers; wear gloves whenever possible when attempting this. Such finger sweeps are performed only on an unconscious person. If a foreign body is strongly suspected but cannot be seen, abdominal thrusts may result in moving or dislodging it so that it is more accessible for removal. (Procedures for managing obstructed airways are presented later.)
If the nurse determines that the person is not breathing, rescue breathing must be performed. In rescue breathing the person's lungs are inflated with oxygen from the rescuer.
It is important to use a one-way filtered mask whenever possible for rescue breathing. Although this chapter refers to "mouth-to-mouth" ventilation, which is used in an emergency, "mask-to-mouth" ventilation is used if a mask is available. The basic procedures are the same in either case.
^ Mouth-to-mouth breathing is a quick and effective way to provide oxygen to a person. The nursing procedure for rescue breathing is given in Nursing Procedure 32-1.
Mouth-to-Nose Ventilation. If it is impossible to open a person's mouth or if an injury to the mouth makes it impossible to make a seal, the mouth-to-nose method may be necessary to replace mouth-to-mouth breathing. In this method, the hand that holds the chin gently presses and holds the mouth shut. The rescuer follows the mouth-to-mouth method but seals his or her lips over the person's nose and breathes in and out.
Check the Pulse
After establishing an airway and breathing for the person, the next step is to check for circulation at the carotid pulse in the neck.
The carotid pulse, rather than a peripheral pulse, is used in a rescue situation. (Rationale: This pulse is close to the heart and is more easily found than the peripheral pulses.) The nurse may use the femoral (groin) pulse in the hospital setting. If the patient is fully clothed, this is difficult to find.
To check the pulse, gently palpate the carotid pulse for 5 to 10 seconds, being careful not to compress the artery. (Note: If the pulse is thready, irregular, or slow, it is difficult to find.) The rescuer should avoid reaching across the patient to palpate the carotid pulse. (Rationale: Pressure may be inadvertently placed on the trachea, obstructing the airway.)
Take the pulse of only one carotid artery at a time. (Rationale: Bilateral pressure on the arteries may accidentally restrict the flow of blood to the brain.)
1. Position the patient's head to keep the airway open:
a) Use the head-tilt/chin-lift maneuver.
Step la. Using the head-tilt/chin-lift maneuver. Reprinted from Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care.
b) Use the jaw-thrust maneuver if a neck injury is suspected.
Step Ib. Using the jaw-thrust maneuver.
(Rationale: This approach does not extend the neck, but opens the airway.)
Step 3. Performing mouth-to-mouth breathing. Reprinted from Cardiopulmonary Resuscitation.
4. Give two full breaths while watching for the patient's chest to rise. Each breath should take from 1 to 1 V2 seconds.
(Rationale: Adequate time provides good chest expansion and decreases the possibility of gastric distention.)
(Rationale: The exhaled air of rescuer breaths contains enough oxygen to support the life of the victim when delivered at this rate.)
7. If first attempt at ventilation is unsuccessful, reposition the patient's head and try again.
(Rationale: Improper positioning of the airway can cause difficulty in ventilating the patient. The most common cause of airway obstruction is the patient's tongue; repositioning will help to move the tongue out of the way.)
8. Use obstructed airway techniques to open the airway if ventilations are still not possible after repositioning. (Rationale: Rescue breathing will be ineffective if airway is obstructed.)
Take time to do a proper assessment. If a pulse is present, ventilate the adult patient 12 times a minute or once every 5 seconds. The child should be ventilated once every 4 seconds. Continue to monitor the pulse, because it may stop. If spontaneous breathing resumes, place the victim in the recovery position if no trauma has been sustained or suspected. In the recovery position, the person is rolled onto the side moving the head, shoulders, and torso simultaneously without twisting.
If the heart is stopped, external chest compressions must be applied. These actions are listed in Nursing Procedure 32-2.
Nurses should learn the techniques of two-person CPR. In the hospital setting, the nurse often works as part of a team, with specialists establishing airways and providing ventilation for the patient and nurses and other healthcare providers giving chest compressions. Two-person CPR is less tiring than single-rescuer CPR; thus, it can be continued longer. Outside the hospital setting, the nurse may work with EMS personnel who are trained in two-person CPR techniques.
Administering External Chest Compressions (Adult)
Supplies and Equipment
Hard surface (ground, floor, or board may be used) Gloves
1. Remove patient's clothing and locate the body landmarks before beginning external chest compressions:
Place the heel of the other hand on the sternum next to the fingers.
(Rationale: This keeps the line of the force of compression on the sternum.)
Step 2. Locating the correct hand position on the sternal notch. Reprinted from Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care,
3. Pick up the lower hand, place on top of the hand on the sternum, and interlace these fingers with those of the hand below.
(Rationale: Using two hands provides the pressure necessary to compress an adult sternum. Interlacing keeps them off the chest and prevents injury to the patient.)
Step 3. Correct hand position for chest compression.
4. Move shoulders directly over hands while keeping arms straight and elbows locked. (Rationale-. This places rescuer in proper position to deliver the most force with the least amount of effort directly downward on the sternum.)
Step 4. Keeping shoulders over victim with fingers interlaced. Adapted with permission from Guidelines for Cardiopulmonary Resuscitation.
5. Using downward pressure, depress the sternum 1 V2 to 2 inches (3-8-5.1 cm).
(Rationale: Compression on the sternum squeezes the heart between the sternum and the spine, simulating a heart contraction. Releasing the compression allows the heart to fill.)
(Rationale: Correct hand position may be lost.)
8. Stop compressions and check carotid pulse after 1 minute (4 cycles of 15 compressions and 2 breaths). If pulse is not felt after 5 seconds, CPR is continued for 4 to 5 minutes before checking pulse again. (Rationale: It is important to deliver as much blood and oxygen to the victim as possible.)
Step 8. Checking the carotid pulse. Reprinted from Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care
Table 32-1. Differences in CPR for Adults, Children, and Infants
* Child between 1 and 8 years old meet with failure. Although hospitalized with a serious duodenal ulcer, all he can talk about is his job and meeting his sales quota.
An airway obstructed by a foreign body will cause respiratory arrest in a short time. Anytime a person (particularly a child) becomes cyanotic, stops breathing, and collapses for no apparent reason, an obstructed airway should be suspected. It is important for the nurse to recognize this situation and take proper action.
In adults, the foreign body obstruction is usually caused by large pieces of food becoming lodged in the airway. Meat is the most common cause. The obstruction may be complete, with no air exchange. It also may be partial, with either a good air exchange or poor air exchange. Poorly fitting dentures and ingestion of alcohol also are associated with obstructed airways.
Although food, especially meat, is the most common cause of an obstructed airway in adults, children may choke on a variety of things.
The "Cafe Coronary." Obstruction of the airway often occurs in restaurants. The person is embarrassed by the incident and often leaves the table. The nurse should be highly suspicious of the person who may have been coughing and gasping, now looks frightened, and suddenly leaves the table. Follow the person, and ask if they are choking. If this person is allowed to go off alone, he or she may die. This is so common an occurrence that it is called a cafe coronary. The patient leaves the table, goes to the restroom, and is found not breathing and without a heartbeat (an apparent heart attack victim).
The patient with a partially obstructed airway with good air exchange will cough forcefully. Wheezing may be present, but adequate air exchange is obvious. Encourage the patient to cough. Do not interfere with attempts to expel the obstruction, and do not leave the person. Offer encouragement and continue to monitor the person. If the person's condition does not rapidly improve, activate the EMS.
Poor air exchange may be identified by ineffective coughing and sometimes by high-pitched wheezing sounds called stridor. The patient, will experience increasing respiratory difficulty and may become cyanotic.
In a complete airway obstruction, the person will be unable to talk, breathe, or cough. The person may even indicate the condition by using the universal signal for choking. This involves clutching the neck between the fingers and thumbs of both hands. The nurse should ask the patient, "Are you choking?" In complete airway obstruction, no oxygen enters the lungs. The patient will soon become unconscious unless the obstruction is removed.
Heimlich maneuver, also called abdominal thrusts,
is used in complete airway obstruction. The procedure may be used for a conscious or unconscious person and for an adult or child. The nursing skills for administering the Heimlich maneuver are given here.
^ If you act immediately, you can force a foreign object out of your own airway. The self-administered action simulates the Heimlich maneuver done by a rescuer. Several thrusts may be needed to clear the airway.
Make a fist with one hand; place the thumb side on the abdomen, above the navel and below the xiphoid process. Grasp the fist with the other hand and press inward and upward toward the diaphragm with a quick motion. If this is unsuccessful, press the upper abdomen quickly over any firm surface, sue as the back of the chair, the side of a table, or railing.
A major cause of death and disability in infants is airway obstruction. Foreign bodies or infections (such as croup and inflammation of the epiglottis) may cause the obstruction. The nurse should learn to recognize the difference between an airway obstruction caused by a foreign object and one caused by swelling of the airway. Obstructed airway procedures will usually clear an airway obstructed by a foreign body, but these procedures could prove fatal if swelling is the cause. The actions for obstructed airway in infants differs from those for adults and children.
Figure 32-2. Heimlich maneuver administered to unconscious victim of foreign-body airway obstruction who is lying down. Reprinted from Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care, Vol. 268, #16, October 28, 1992, p. 2193. Copyright 1992 American Medical Association.
Managing an Obstructed in an Infant
Figure 32-3. Back blows (top) and chest thrusts (bottom) to relieve foreign-body airway obstruction in the infant. Reprinted from Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care
As soon as medical or paramedical assistance arrives, the nurse's role is to assist. If in the hospital, activate the signal for a "code" in your facility. Obtain the necessary emergency equipment: crash cart; manual breathing bag; emergency drugs; heart monitor; stethoscope; equipment for blood pressure, oxygen, intravenous (IV) line, and suctioning; and oral airways. If the resuscitation measures are successful, the pulse will be felt, the pupils will constrict, the patient's color will improve, and breathing will resume.
The patient may cough or move. If you are assisting a code team and suction is available, the patient's head should be turned to the side and suction used. Fingers should not be placed in a patient's mouth unless absolutely necessary. Always wear gloves.
Once the patient is resuscitated, a mechanical ventilator, IV therapy, or vasopressor drugs may be needed for maintenance. Until the physician decides that the person is out of danger, the patient will need to be watched closely in case another emergency resuscitation is required.
Document the entire procedure, including the time the arrest was discovered; your estimation of when the arrest occurred; the emergency measures you took; the time the code team arrived; the procedures performed from that time on; the drugs given, their dosage, and the time; the responses made by the patient; and the laboratory work done, as well as electrocardiograms, x-rays, and other tests. Finally, note the outcome of the resuscitation efforts and the subsequent nursing care if the attempt was successful.
6.1. Basic :
Methodical instruction was prepared by
Assistant Riabyi S.I.
A review is positive, associate professor Chomko O.J.
Materials of control of base level of preparation of students: tests.
Choose the correct answer/statement:
Real-life situations to be solved:
Answers to the Self-Assessment:
– Clinical death.
|Higher nurse education||Higher nurse education|
|Higher nurse education||Higher nurse education|
|Higher nurse education||Higher nurse education|
|Higher nurse education||Higher nurse education|
|Higher nurse education||Higher nurse education|