Table of Contents

I. Triage 2

II. Primary Survey 2

III. Secondary Survey 9

IV. Emergency Disorders 10

A. Coronary Artery Disease & Acute Coronary Syndromes 10

B. Cerebrovascular Accident 16

C. Increased Intracranial Pressure (ICP) 18

D. Traumatic Head Injury 20

E. Spinal Cord Injury 22

F. Renal Failure 25

G. Burns 28

H. DKA (Diabetic Ketoacidosis) 29

/ HHNS (Hyperglycemic Hyperosmolar Nonketotic Syndrome)

I. Thyroid Crisis – (Thyroid Storm/ Thyrotoxicosis) 30

J. Multi- Organ Dysfunction 30

K. Airway Obstruction 31

L. Shock 32

M. Wounds 33

N. Chronic Obstructive Pulmonary Disease 34

O. Asthma 36

P. Acute Respiratory Distress Syndrome (Mechanical Ventilation) 37

Q. Liver Cirrhosis 40

R. Esophageal Varices 42
S. Poisoning 44
T. Substance Abuse 45
V. Emergency Drugs 48
VI. Normal Laboratory Values 53
VII. Common Medical Abbreviations 54

1
I: TRIAGE (EMERGENCY DEPARTMENT)
- Is “to sort” in the daily routine of the emergency department. It is used to sort the patient
in the following categories:
EMERGENT- highest priority
URGENT- higher priority
NON-URGENT- priority of care

PRIMARY ASSESSMENT (ABCD)

- Immediately life- threatening problems are identified during the primary assessment.
Airway, breathing, and circulation are evaluated while maintaining stability of the
cervical spine. D is for neurologic deficit, including level of consciousness and pupillary
reaction.
SECONDARY ASSESSMENT (EFGHI)
- Is a brief (two to three minute) examination of the patient intended to detect and prioritize
injuries. E. is for exposure: remove clothing check for signs of injury. F is for full set of
vital signs and five interventions (monitors, pulse oximetry, indwelling urinary catheter,
nasogastric tube, and labs). G: give comfort measures. H is for head to toe examination.
I: inspect the back – turn the patient.

PRIMARY SURVEY SECONDARY SURVEY

A- Airway E- Exposure to environment
B- Breathing F- Full set of vital signs
C- Circulation G- Give comfort
D- Disability H- History collection
I- Inspect the posterior surface

Recent advances in secondary survey – AMPLE

A-Allergy
M- Medication History
P- Past health history
L- Last meal
E- Events/ Environment preceding illness or injuries

II: THE PRIMARY SURVEY

• Examine, diagnose, treat life-threatening injuries as soon as they are diagnosed

• Use simplest treatment possible to stabilize patient’s condition

A. Airway
B. Breathing
C. Circulation
D. Disability or neurologic Damage
E. Expose the patient

Purpose is to identify and treat life threatening injuries:

– Airway obstruction
– Breathing difficulties
– Severe external or internal hemorrhage

2
 A. AIRWAY
Always assess the airway
• Talk to the patient
– A patient speaking freely and clearly has an open airway
• Look and listen for signs of obstruction
– Snoring or gurgling
– Stridor or noisy breathing
– Foreign body or vomit in mouth
• If airway obstructed, open airway and clear
obstruction

TECHNIQUES FOR OPENING THE AIRWAY

No trauma
• Position patient on firm surface
• Tilt the head
• Lift the chin to open the airway
• Remove foreign body if visible
• Clear secretions
• Give oxygen 5 L/min

TECHNIQUES FOR OPENING THE AIRWAY

In case of trauma
• Stabilize cervical spine
• Do not lift head!
• Open airway using jaw thrust
• Remove foreign body if visible
• Clear secretions
• Give oxygen 5 L/min

AIRWAY DEVICES
Oropharyngeal airway
• Use if patient unconscious
• Use correct size - measure from front of ear to corner of
mouth
• Slide airway over tongue
• If patient resists, gags or vomits, remove immediately!

3
Nasopharyngeal airway
• Better tolerated if patient is semi-conscious
• Pass well lubricated into one nostril
• Direct posteriorly, towards the throat

AIRWAY
Before attempting intubation, the answer to these
questions should be YES:
Is there an indication?
- Failure to maintain or protect the airway (risk of
aspiration) or
- Failure to oxygenate or ventilate or
- Impending airway failure (inhalation injury,
angioedema)
Do you have working equipment?
- Functioning laryngoscope with working light
- Appropriate endotracheal tube size
- Bag-valve mask
- Working oxygen source
- Suction
Do you have a post-intubation plan?
- Is a mechanical ventilator available? (unless only
short-term need)
- Are sedative drugs available?

B. BREATHING
Assess ventilation - Is the patient in respiratory distress?
Look - For cyanosis, wounds, deformities, ecchymosis, amplitude, paradoxical movement
Feel - Painful areas, abnormal movement Percuss - Dullness
Listen - Reduced breath sounds
4
INDICATIONS FOR CHEST DECOMPRESSION
Signs and Symptoms
– Absent or diminished breath sounds on one side
– Evidence of chest trauma or rib fracture
– Open or "sucking" chest wound Diagnoses
– Pneumothorax
– Tension pneumothorax
– Hemothorax
– Hemo-pneumothorax

OPEN CHEST WOUND

•"Sucking" sound
•Requires very prompt treatment
– Apply an occlusive "plastic pack" dressing to wound,
tape down on three sides, leaving one side open for air to
escape
•Place a chest drain
•Never insert chest tube through wound
•Give high flow oxygen
•Give antibiotics
•Debride wound and consider closure

TENSION PNEUMOTHORAX
• Air from lung puncture enters pleural space, cannot escape
• Progressive increase in intrathoracic pressure causes
mediastinal shift and hypotension due to reduced venous
return
• Patient becomes short of breath and hypoxic
• Diminished breath sounds on side of pneumothorax
• Requires urgent needle decompression, then chest drain as
soon as possible increasing

TENSION PNEUMOTHORAX
• Give high flow oxygen
• After aseptic skin preparation
• Insert a large bore needle over rib:
– 2nd intercostal space – Over 3rd rib at mid-clavicular line
• Listen for hissing sound of air escaping
• Insert chest drain

5
 C. CIRCULATION

HEMORRAGHIC SHOCK

Assess the circulation Signs of hypoperfusion

– Confusion, lethargy or agitation
– Pallor or cold extremities
– Weak or absent radial and femoral pulses
– Tachycardia
– Hypotension
➢ Examine the abdomen for tenderness or guarding
➢ Carefully assess pelvic stability
➢ Large volumes of blood may be hidden in thoracic, abdominal and pelvic cavities, or
from femoral shaft fractures.
➢ To decrease bleeding:
• Apply pressure to external wounds
• Apply splint to possible femur fracture
• Apply pelvic binder to possible pelvic fracture
➢ If patient is pregnant, she should not be on her back, put her on her left side.
➢ Send blood for type and crossmatch
➢ Obtain two large bore IV catheters If systolic BP <90 mmHg or pulse >110 bpm
• Give 500 ml bolus of Ringer’s Lactate or NS
• Keep patient warm
• Reassess vitals
• If still hypotensive after 2L of crystalloids, transfuse blood

6
 ➢ STOP THE BLEEDING
Apply direct pressure to the wound, then put on compression
dressing. Apply only enough pressure to stop the bleeding.
ONLY if bleeding is life-threatening and cannot be controlled,
apply a tourniquet. Use a blood pressure cuff or wide elastic
band over padded skin. Transfer urgently!

D. DISABILITY or DAMAGE

Checking for neurological damage: vital part of primary survey Abbreviated neurological
examination:

– ALERT
– VERBAL - responsive to verbal stimulus
– PAIN - responsive to painful stimulus
– UNRESPONSIVE

Eyes +Verbal + Motor Scores = GCS

– Severe head injury: GCS 8 or less
– Moderate head injury: GCS 9-12
– Mild head injury: GCS 13-15
GCS is to be repeated and recorded frequently. It is the best way to determine deterioration

7
HEAD INJURY
Deterioration
– Unequal or dilated pupils may indicate
increased intracranial pressure
– Avoid sedation or analgesics as it interferes
with neurologic examinations, reduces
breathing (increased CO2 causes increased
intracranial pressure)
– Bradycardia, hypertension may indicate
worsening condition

E. EXPOSURE
• Remove all patient's clothing
• Examine whole patient
• Front and back; log roll carefully
• Do not allow patient to get cold (especially children)
IMAGING
X-Rays
- Chest
- Pelvis
- Cervical spine Ultrasound
- FAST scan

8
III: SECONDARY SURVEY
• Perform complete, thorough patient examination to ensure no other injuries are missed

Head Exam – Scalp, eyes, ears – Soft tissues

Neck Exam – Penetrating injuries – Swelling or crepitus
Neurological Exam – Glasgow Coma Score – Motor examination – Sensory examination –
Reflexes
Chest Exam – Clavicles, ribs – Breath, heart sounds
Abdominal Exam – Penetrating injury – Blunt injury: nasogastric tube – Rectal exam – Urinary
catheter
Pelvis and Limbs – Fractures – Pulses – Lacerations, ecchymosis

REASSESSMENT
• Always perform an ABCDE primary survey if patient deteriorates
• Signs of adequate resuscitation
– Slowing of tachycardia
– Urine output normalizes
– Blood pressure increases

MONITORING
• EKG monitoring if available
• Pulse oximeter
– Most widely used physiological monitoring device for
heart rate, oxygenation
– Especially useful in anesthesia, ICU – Simple to use
– Should be minimum standard of monitoring in every
surgical theatre
• Blood pressure – Manually or automated machine

9
IV: EMERGENCY DISORDERS
A. Coronary Artery Disease & Acute Coronary Syndromes
- Incomplete occlusion of the coronary arteries that lead to Angina (ischemia)
- Complete occlusion of the coronary arteries that lead to Myocardial Infarction
- The heart will pump harder to meet the O2 demand leading to Congestive Heart
Failure.
Non- Modifiable Risk Factors of CAD/ ACS
a. Age
b. Gender
c. Race
d. Heredity
Modifiable Factors

CARDIOVASCULAR ASSESSMENT
a. Chest Pain
- Most common
- Due to Ischemia or MI
- Precipitated by stress or can
be relieved by Nitroglycerin
(NTG)
- In MI, it is more intense,
unrelated to activities and
can’t be relieved by NTG
- If it occurs during breathing,
suspect respiratory problems
b. Dyspnea
- subjective feeling (inability to get enough air).
- Dyspnea on exertion is due to increased O2 myocardial demand.
- Orthopnea is related to blood pooling in the pulmonary bed; suspect Pulmonary
Edema
- Any sudden or acute dyspnea may be a sign of Pulmonary Embolism
10
 c. Cough/sputum
- Mucoid and foamy sputum can be a sign of CHF
- Pink-tinged frothy appearance may signal Pulmonary Edema.
- Whitish, viral infection
- Change in color other than the above mentioned may signify bacterial infection.
d. Cyanosis
- Bluish discoloration of the skin and mucous membrane
- Sat O2 is below 90%
e. Fatigue
- May be due to Anemias or related to decreased Cardiac Output
f. Palpitations
- Awareness of rapid or irregular heart beat
- Autonomic Nervous System and Adrenal Glands response (stress)
g. Syncope
- Transient loss of consciousness
- Due to decreased cerebral tissue perfusion
h. Edema
- Due to: Increased Hydrostatic Pressure (HP),
Decreased Colloidal Oncotic Pressure (COP) ,
Obstructed Lymphatic or Vascular System, or
Related to Inflammatory reaction
Types:
a. Bilateral edema = CHF or Renal Failure
b. Unilateral edema = Vascular or Lymphatic
obstruction
c. Non-pitting edema = Inflammatory
d. Pitting edema = HP and COP derangement
i. Skin
- Color, temperature, hair growth, nails, capillary refill
- spooning of fingers /clubbing of fingers
j. Vital Signs
- Heart rate – 60-100
- Rhythm – regular or irregular
- Bruits and Thrills – murmur like; vascular in origin -
palpate a thrill, auscultate a bruit
- Blood Pressure
- Jugular venous pressure
- Tachycardia= ↑ 100 beats/minute
- Bradycardia= ↓ 60 beats/minute
- Arrhythmias = irregular rate and rhythm
- Murmurs - turbulence of blood flow; if positive watch out for FVE; normal until
1 year old
- Pericardial Friction Rub - “squeaking sound”; suspect pericardial effusion if this
is heard
- Muffled Heart Sound - if positive rule out Cardiac Tamponade and other similar
problems like Effusion

Laboratory & Diagnostic Test

a. Complete Blood Count- RBC suggest tissue oxygenation. Elevated WBC may indicate
infectious heart disease and MI.
b. Erythrocyte Sedimentation Rate (ESR)- It is elevated in infectious heart disorder or MI.
Normal range: Males: 15-20mm/hr. Females: 20-30 mm/hr.

11
 c. Blood Coagulation Test:
1. Prothrombin Time (PT, Pro Time)- It measures time required for clotting to occur.
Used to evaluate effectiveness of COUMADIN. Normal range 11-16 secs.
2. Partial Thromboplastin Time (PTT)- Best screening test for disorders of coagulation.
Used to determine the effectiveness of HEPARIN. Normal Range: 60-70 secs.
d. Blood Urea Nitrogen (BUN)- Indicator of renal function Normal Range: 10-20mg/dl (5-
25mg/dl is also accepted).
e. Blood Lipids:
1. Serum Cholesterol: 150-200mg/dl
2. Serum Triglycerides: 140-200mg/dl.
f. Serum Enzymes Studies
1. Aspartate Aminotransferase (AST)- Elevated level indicates tissue necrosis. Normal
Range: 7-40mu/ml
2. CK-MB- Elevated 4-6hrs from the onset of infarction; peaks 24-36 hrs. return to
normal 4-7 days. Normal Range: males: 50-325mu/ml; Females: 50-250mu/ml
3. Lactic Dehydrogenase (LDL)- Onset: 12hrs; Peak: 48hrs; returns to normal: 10-14
days
4. Hydroxybutyrate Dehydrogenase (HBD)- it is valuable in detecting silent MI because
it is elevated for a long period of time. Onset: 10-12hrs; Peaks: 48-72hrs; Returns to
Normal 12-13 days
5. Troponin- Most specific lab test to detect MI. Troponin has 3 compartments: I, C, &
T. Troponin I persist for 4-7 days.
g. Serum Electrolytes/ Blood
Chemistry:
1. Sodium (Na)
2. Potassium (K)
3. Calcium (Ca)
4. Magnesium (Mg)
5. Glucose
6. Glycosylated Hemoglobin
(Hemoglobin A1c)
h. ECG/ EKG- ST segment
elevation and T wave inversion
i. Radiologic Findings
- Chest X-Ray
j. Hemodynamic Monitoring
- Swan-Ganz Catheterization -
Right side of the heart,
Pulmonary artery pressure
Pulmonary artery occlusive
pressure, Right atrial
pressure and Cardiac output
k. Coronary Angiogram
- allows to visualize narrowing
or obstructions
- therapeutic measures can
follow immediately

Goals
➢ Pain relief
➢ Reduction of myocardial oxygen consumption
➢ Prevention and treatment of complications

12
INTERVENTIONS:
1. Admit to the CCU/ ICU
2. Activity
- Day 1: bed rest, if stable
- Day 2-3: bed rest, but patient may be allowed to sit on a chair for 15-20 minutes
- Early mobilization is recommended for uncomplicated AMI
3. Monitoring Vital Signs
- First 6 hours- q30-60 minutes
- Next 24 hours- q 2 hours
- Thereafter q 4 hours
4. Diet
- NPO: 1st 24 hours
- If stable low salt, low cholesterol diet
5. IV Fluids
- D5W to KVO If unable to take food/ fluid per Orem
- 1000ml/8 hours
- K supplement
6. Medication
➢ Morphine SO4 (2-5mg/IV dose) - Potent analgesic, Peripheral venous
vasodilation, Pulmonary venous distention
➢ Tranquilizers- to decrease anxiety Ex. Diazepam (5-10 mg per IV/Orem)
➢ Laxative- to prevent straining during defecation Ex. Lactulose (HS)
➢ Beta Blockers - Hyperdynamic states, HPN w/o evidence of heart failure -
Reduce myocardial oxygen consumption by decreasing: BP. Heart Rate,
Myocardial Contractility and calcium output.
Ex. Propranolol, Metoprolol, Atenolol
Nursing Consideration:
1.Assess Pulse Rate before administration; withhold if bradycardia is present.
2.Administer with food, may cause GI upset.
3.Do not administer with asthma it causes Bronchoconstriction.
4.Do not give to patient with DM, it causes hypoglycemia.
5.Antidote for Beta Blocker poisoning is Glucagon
➢ Nitrates - Act by augmenting perfusion at the border of ischemic zone.
Generalized vasodilation, reducing myocardial O2 demand, lowering preload,
Lowering afterload
Ex: IV Nitroglycerine, Sublingual Nitroglycerine, Oral/Transdermal
Nitroglycerine
Nursing Considerations:
1.Only a maximum of 3 doses at 5 min. interval.
2.Offer sips of water before giving it sublingually.
3.Store the medication in a cool, dry place; use dark /amber container.
4.If side effects are noticed do not discontinue the drug this is usual in the first
few doses of medication.
5.Rotate skin sites for nitro patch.
➢ ACE inhibitors-reduce mortality rates after MI.
- Administer ACE inhibitors as soon as possible
- ACE inhibitors have the greatest benefit in patients with ventricular dysfunction.
- Continue ACE inhibitors indefinitely after MI.
- Angiotensin-receptor blockers may be used as an alternative adverse effects,
such as a persistent cough.
➢ Aspirin and/or antiplatelet therapy- Continue aspirin indefinitely, Clopidogrel
may be used as an alternative only if resistance or allergy to aspirin.
Nursing Considerations:
1.Assess for signs and symptoms of Bleeding.
2.Avoid straining at stool to avoid rectal bleeding.
13
 3.It should be given with food.
4.Observe for toxicity- Tinnitus (ringing of ears).
5.May cause Bronchoconstriction- Observe for wheezing.
➢ Heparin
1.Assess for S/S of Bleeding.
2.Keep Protamine Sulfate available.
3.If used SQ. do not aspirate to prevent hematoma formation.
4.Monitor for PTT or APTT
5.Used for a maximum of 2 weeks.
➢ Coumadin (Warfarin Sodium)
1.Assess for bleeding
2.Keep Vitamin K available.
3.Monitor for Prothrombin Time
4.Do not give together with aspirin to prevent bleeding.
5.Minimize green leafy vegetables in the diet
➢ Thrombolytic therapy
The effectiveness:
- highest in the first 2 hours
- After 12 hours, the risk associated with thrombolytic therapy outweighs any
benefit
- contraindicated on unstable angina and NSTEMI, and for the treatment of
individuals with evidence of cardiogenic shock
- streptokinase, urokinase, and alteplase (recombinant tissue plasminogen activator,
rtPA), reteplase, tenecteplase
Surgical Care
A. Percutaneous Transluminal Coronary Angioplasty
- treatment of choice
- PCI provides greater coronary patency
- lower risk of bleeding and instant knowledge about the extent of the underlying
disease.
- A specially designed balloon – tipped catheter is inserted under fluoroscopic
guidance and advance to the site of the obstruction.
B. Intravascular Stenting
- Biologic Stent is
produced through
coagulation of
collagen, elastin
and other tissues in
the vessel wall by
laser,
photocoagulation
or radio frequency.
- It is done to
prevent restenosis
after Percutaneous
Transluminal
Coronary
Angioplasty.

14
 C. Emergent or urgent coronary artery graft bypass
surgery (CABG)
- is indicated
- angioplasty fails
- Severe narrowing of 1 or more coronary
artery.
- Commonly used: Saphenous vein and
internal mammary artery
- Complications – Inflammation, Mechanical,
Electrical abnormalities

Cardiac Rehabilitation
➢ A process which a person restored to health and maintains optimal
physiologic, psychosocial and recreational functions.
➢ Begins with the moment a client is admitted to the hospital for emergency
care, it continues for months and even years after the client is discharged from
the health care facility.
➢ Goals of Rehabilitation:
1.To live as full, vital and productive life as possible.
2.Remain within the limits of the heart’s ability to respond to activity and
stress.
Activities:
a. Exercise may gradually implement from the hospital onwards.
b. Exercise session is terminated if any one of the following occurs:
cyanosis, cold sweats, faintness, extreme fatigue, severe dyspnea, pallor,
chest pain, PR more than 100/ min., dysrhythmias greater than
160/95mmHg.
Teaching and Counseling:
a. Self- management education guide.
b. Control hypertension with continued medical supervision.
c. Diet
d. Weight reduction program
e. Progressive exercise
f. Stress management techniques
g. Resumption of sexual activity after 4-6 weeks from discharge, if
appropriate.
h. Teaching guide on resumption of sexual activities:
Assume less fatiguing position.
The non- MI partner take the active role
Take nitroglycerine before sexual activity
If dyspnea, chest pain or palpitations occur, moderation should be observed;
if symptom persist stop sexual activity.
Develop other means of sexual expression.

15
 B. CEREBROVASCULAR ACCIDENT
- is a sudden loss of function resulting from disruption of the blood supply to a part
of the brain.
CAUSES
➢ Ischemic
- Large artery thrombosis
- Small penetrating artery thrombosis
- Cardiogenic embolic
- Cryptogenic (no known cause)
➢ Hemorrhagic
- Intracerebral hemorrhage
- Subarachnoid hemorrhage
- Cerebral aneurysm
- Arteriovenous malformation

Risk factors
- Atherosclerosis
- Hypertension
- Anticoagulation therapy
- Diabetes mellitus
- Stress
- Obesity
- Oral contraceptives
ASSESSMENT:
1. Assessment findings depend on the area of the
brain affected
2. Lesions in the cerebral hemisphere result in
manifestations on the contralateral side, which is
the side of the body opposite the stroke.
3. Diagnosis is determined by a CT scan,
electroencephalography, cerebral arteriography,
and MRI.
16
4. Airway patency is always a priority.
5. Pulse (may be slow and bounding)
6. Respirations (Cheyne-Stokes)
7. Blood pressure (hypertension)
8. Headache, nausea, and vomiting
9. Facial drooping
10. Nuchal rigidity
11. Visual changes
12. Ataxia
13. Dysarthria
14. Dysphagia
15. Speech changes
16. Decreased sensation to pressure, heat, and cold
17. Bowel and bladder dysfunctions
18. Paralysis
19. Aphasia

17
 INTERVENTIONS:

➢ Maintain a patent airway and administer oxygen as prescribed.

➢ Monitor vital signs.
➢ Usually a blood pressure of 150/100 mm Hg is maintained to ensure cerebral perfusion.
➢ Suction secretions to prevent aspiration as prescribed, but never suction nasally or for longer
than 10 seconds to prevent increased ICP.
➢ Monitor for increased ICP because the client is most at risk during the first 72 hours
following the stroke.
➢ Position the client on the side to prevent aspiration, with the head of the bed elevated 15 to
30 degrees as prescribed.
➢ Provide soft and semisoft foods and flavored, cool or warm, thickened fluids rather than thin
liquids because the stroke client can tolerate these types of food better; speech therapists may
do swallow studies to recommend consistency of food and fluids.
➢ When the client is eating, position the client sitting in a chair or sitting up in bed, with the
head and neck positioned slightly forward and flexed.
➢ Place food in the back of the mouth on the unaffected side to prevent trapping of food in the
affected cheek.
➢ Place a patch over the affected eye if the client has diplopia.

C. INCREASED INTRACRANIAL PRESSURE (ICP)

- Increased ICP may be caused by trauma, hemorrhage, growths or tumors,
hydrocephalus, edema, or inflammation.
- Increased ICP can impede circulation to the brain, impede the absorption of CSF,
affect the functioning of nerve cells, and lead to brainstem compression and death.
ASSESSMENT:

1. Altered level of consciousness, which is the most

sensitive and earliest indication of increasing ICP
2. Headache
3. Abnormal respirations
4. Rise in blood pressure with widening pulse pressure
5. Slowing of pulse
6. Elevated temperature
7. Vomiting
8. Pupil changes
9. Late signs of increased ICP include increased systolic blood pressure, widened pulse
pressure, and slowed heart rate.
10. Other late signs include changes in motor function from weakness to hemiplegia, a
positive Babinski reflex, decorticate or decerebrate posturing, and seizures.

18
 INTERVENTIONS:
➢ Monitor respiratory status and prevent hypoxia.
➢ Avoid the administration of morphine sulfate to prevent
the occurrence of hypoxia.
➢ Maintain mechanical ventilation as prescribed;
maintaining the PaCO2 at 30 to 35 mm Hg (30 to 35
mm Hg) will result in vasoconstriction of the cerebral
blood vessels, decreased blood flow, and therefore
decreased ICP.
➢ Maintain body temperature.
➢ Prevent shivering, which can increase ICP.
➢ Decrease environmental stimuli.
➢ Monitor electrolyte levels and acid-base balance.
➢ Monitor intake and output.
➢ Limit fluid intake to 1200 mL/day.
➢ Instruct the client to avoid straining activities, such as
coughing and sneezing.
➢ Instruct the client to avoid Valsalva’s maneuver.
Note: For the client with increased ICP, elevate the head of
the bed 30 to 40 degrees, avoid the Trendelenburg position,
and prevent flexion of the neck and hips.

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 D. TRAUMATIC HEAD
INJURY
- Head injury is trauma to the skull,
resulting in mild to extensive
damage to the brain.
- Immediate complications include
cerebral bleeding, hematomas,
uncontrolled increased ICP,
infections, and seizures.
- Changes in personality or behavior,
cranial nerve deficits, and any other
residual deficits depend on the area
of the brain damage and the extent
of the damage.
Types of head injuries
a. Open
- Scalp lacerations
- Fractures in the skull
- Interruption of the dura mater
b. Closed
- Concussions
- Contusions
- Fractures
c. Hematoma - collection of blood in the tissues that can occur as a result of a subarachnoid
hemorrhage or an intracerebral hemorrhage.
ASSESSMENT:
1. Changes in level of consciousness
2. Airway and breathing pattern changes
3. Vital signs change, reflecting increased ICP
4. Headache, nausea, and vomiting
5. Visual disturbances, pupillary changes, and papilledema
6. Nuchal rigidity (not tested until spinal cord injury is ruled out)
7. CSF drainage from the ears or nose
8. Weakness and paralysis
9. Posturing
- Flexor (decorticate posturing)
a. Client flexes 1 or both arms on the chest and may extend the legs stiffly.
b. Flexor posturing indicates a nonfunctioning cortex.
- Extensor (decerebrate posturing)
a. Client stiffly extends 1 or both arms and possibly the legs.
b. Extensor posturing indicates a brainstem lesion.
- Flaccid posturing: Client displays no motor response in any extremity.
10. Decreased sensation or absence of feeling
11. Reflex activity changes
12. Seizure activity
INTERVENTIONS:
➢ Monitor respiratory status and maintain a patent airway because increased carbon dioxide
(CO2) levels increase cerebral edema.
➢ Monitor neurological status and vital signs, including temperature.
➢ Monitor for increased ICP.
➢ Maintain head elevation to reduce venous pressure.
➢ Prevent neck flexion.
20
 ➢ Initiate normothermia measures for increased temperature.
➢ Assess cranial nerve function, reflexes, and motor and sensory function.
➢ Initiate seizure precautions.
➢ Monitor for pain and restlessness.
➢ Morphine sulfate may be prescribed to decrease agitation and control restlessness caused
by pain for the head-injured client on a ventilator; administer with caution because it is a
respiratory depressant and may increase ICP.
➢ Monitor for drainage from the nose or ears because this fluid may be CSF.
➢ Do not attempt to clean the nose, suction, or allow the client to blow his or her nose if
drainage occurs.
➢ Do not clean the ear if drainage is noted, but apply a loose, dry sterile dressing.
➢ Check drainage for the presence of CSF.
➢ Notify the HCP if drainage from the ears or nose is noted and if the drainage tests
positive for CSF.
➢ Instruct the client to avoid coughing because this increases ICP.
➢ Monitor for signs of infection.
➢ Prevent complications of immobility.
➢ Inform the client and family about the possible behavior changes that may occur,
including those that are expected and those that need to be reported.

Surgical intervention:
CRANIOTOMY
- involves an incision through the cranium to remove accumulated blood or a tumor
- complications of the procedure include increased ICP from cerebral edema,
hemorrhage, or obstruction of the normal flow of CSF.
- Additional complications include hematomas, hypovolemic shock, hydrocephalus,
respiratory and neurogenic complications, pulmonary edema, and wound infections.
- Complications related to fluid and electrolyte imbalances include diabetes insipidus
and inappropriate secretion of antidiuretic hormone.

21
- Stereotactic radiosurgery (SRS) may be an alternative to traditional surgery and is
usually used to treat tumors and arteriovenous malformations.

E. SPINAL CORD INJURY

- Trauma to the spinal cord causes partial or complete disruption of the nerve tracts
and neurons.
- The injury can involve contusion, laceration, or compression of the cord.
- Spinal cord edema develops; necrosis of the spinal cord can develop as a result of
compromised capillary circulation and venous return.
- Loss of motor function, sensation, reflex activity, and bowel and bladder control
may result.
- The most common causes include motor vehicle crashes, falls, sporting and
industrial accidents, and gunshot or stab wounds.
- Complications related to the injury include respiratory failure, autonomic
dysreflexia, spinal shock, further cord damage, and death.
- Most frequently involved vertebrae
1. Cervical—C5, C6, and C7
2. Thoracic—T12
3. Lumbar—L1

22
Assessment:
a. Cervical injuries
- Injury at C2 to C3 is usually fatal.
- C4 is the major innervation to the diaphragm by the phrenic nerve.
- Involvement above C4 causes respiratory difficulty and paralysis of all four
extremities.
- The client may have movement in the shoulder if the injury is at C5 through C8, and
may also have decreased respiratory reserve.
b. Thoracic level injuries
- Loss of movement of the chest, trunk, bowel, bladder, and legs may occur,
depending on the level of injury.
- Leg paralysis (paraplegia) may occur.
- Autonomic dysreflexia with lesions or injuries above T6 and in cervical lesions
may occur.
- Visceral distention from noxious stimuli such as a distended bladder or an
impacted rectum may cause reactions such as sweating, bradycardia,
hypertension, nasal stuffiness, and goose flesh.
c. Lumbar and sacral level injuries
- Loss of movement and sensation of the lower extremities may occur.
- S2 and S3 center on micturition; therefore, below this level, the bladder will
contract but not empty (neurogenic bladder).
- Injury above S2 in males allows them to have an erection, but they are unable to
ejaculate because of sympathetic nerve damage.
- Injury between S2 and S4 damages the sympathetic and parasympathetic response,
preventing erection or ejaculation.
Note: Always suspect spinal cord injury when trauma occurs until this injury is ruled out.
Immobilize the client on a spinal backboard with the head in a neutral position to prevent an
incomplete injury from becoming complete.

Interventions:
➢ Assess the respiratory pattern and maintain a patent
airway.
➢ Prevent head flexion, rotation, or extension.
➢ During immobilization, maintain traction and alignment on
the head by placing hands on both sides of the head by the
ears.
➢ Maintain an extended position.
➢ Logroll the client.
➢ No part of the body should be twisted or turned, and the
client is not allowed to assume a sitting position.

23
➢ In the emergency department, a client who has sustained a cervical fracture should be
placed immediately in skeletal traction via skull tongs or halo traction to immobilize
the cervical spine and reduce the fracture and dislocation

24
 F. RENAL FAILURE
1. ACUTE RENAL FAILURE
- Rapid onset of oliguria (<400 ml /day) , with severe rise in BUN & creatinine
(Azotemia – accumulation of nitrogen in blood )

Stages of Acute Renal Failure

- Onset – 1-3 days with ^ BUN and creatinine and possible decreased UOP
- Oliguric – UOP < 400/d, ^BUN, CREA, Phosphorus, K, may last up to 14 days
- Diuretic – UOP ^ to as much as 4000 mL/d but no waste products, at end of this
stage may begin to see improvement
- Recovery – things go back to normal or may remain insufficient and become
chronic
Complication of ARF - Hyperkalemia – most dangerous complication, may lead to cardiac arrest
if rise in K+ is too fast
Nursing Care ARF
- Daily Weight
- CVP monitoring
- Diuretic as prescribed
- Low protein, K, Na & high carbohydrate diet
- Emergency management of Hyperkalemia: insulin & dextrose Kayexalate enema
25
 2. CHRONIC RENAL FAILURE
- irreversible progressive reduction of functioning renal tissue.
Common causes CRF
- Diabetic nephropathy
- Hypertensive nephropathy
- Glomerulonephritis
- Chronic pyelonephritis
Stages CRF
a. Reduced Renal Reserve high BUN no clinical symptoms yet
b. Renal insufficiency- mild azotemia, impaired urine concentration, nocturia
c. Renal failure – Severe azotemia, acidosis, concentrated urine, severe anemia &
electrolyte imbalances
Signs/ Symptoms
- Hyper K, Hypernatremia, Hypocalcemia
- Anemia
- Anorexia, nausea & vomiting
- Ammoniacal breath
- Immunosuppression
- HPN, CHF
- Pulmonary edema
- Severe pruritus
- Peripheral neuropathy
- Uremic amaurosis
Nursing Care ESRD
➢ Low Protein, Low Na diet
➢ Prepare client for peritoneal / hemodialysis
➢ Monitor Anemia
➢ Administer epoetin alpha (Epogen), diuretics, antihypertensives as prescribed
➢ Kidney transplant

26
HEMODIALYSIS:
Is the diffusion of dissolved particles from the blood
into the dialysate bath of the hemodialysis machine
across the semipermeable membrane of the dialyzer.
Hemodialysis requires vascular access:
- Subclavian vein/ Femoral vein
(temporary)
- Arteriovenous fistula, arteriovenous
shunt/arteriovenous graft

Nursing Management:
1. Assess the integrity of the hemodialysis access site
2. Monitor VS
3. Assess client for fluid overload
4. Weigh the client before and after the dialysis treatment (to determine fluid loss)
5. Hold meds that can be dialyzed off
6. Monitor for SS of Shock & Disequilibrium syndrome
Complication:
Disequilibrium Syndrome – is the rapid change in composition of extracellular fluid where the
solutes of the blood are removed from the blood faster than that of the CSF, causing osmotic
movement of fluid into the CSF causing cerebral edema.
Nursing Management: Disequilibrium syndrome:
1. Assess for Nausea & vomiting
2. Assess for headache, Restlessness, agitation & or confusion
3. Watch out for seizures
4. Notify physician if SS of disequilibrium syndrome occurs
5. Reduce environmental stimuli
6. Dialyze the patient at a shorter period and at a slower rate

27
 G. BURNS
- cell destruction of the layers of the skin and resultant depletion of fluid and
electrolytes
Types of Burns
a. Thermal: exposure to flame
b. Chemical: exposure to strong acids or alkali
c. Electrical: Caused by electrical strong electrical current results in internal tissue injury
Burn Depth:
a. Superficial thickness burn (1st degree)- mild to severe erythema of skin, blanches with
pressure – heals in 3-7 days
b. Partial thickness burn (2nd degree) – large blisters; painful heals 2-3 weeks
c. Full thickness burn (3rd degree) – white yellow deep red to black (eschar) disruption of
blood flow, no pain; scarring and wound contractures will develop. Grafting is required;
healing takes weeks to months
d. Deep full thickness burn (4th degree) – Involves injury to muscle and bone= appears
black(eschars) – hard and inelastic healing takes weeks to months; grafts are required
Nursing Diagnosis: Decreased Cardiac output Related to Fluid shifts

PARKLAND (BAXTER) FORMULA FOR FLUID REPLACEMENT

- 4ml Lactated Ringer’s sol x Kg body mass x total percentage of body surface
burned
24 HOUR FLUID REPLACEMENT
- 1st 8 hours = ½ of total
- next 8 hours = ¼ of total
- last 8 hours= ¼ of total
MANAGEMENT OF BURNS:
1. Administer fluids as prescribed
2. Maintain a high calorie, high protein diet
3. Monitor intake and output
4. Monitor for infections of burn site

28
Burn Medications:
- Nitrofurazone (Furacin) – broad spectrum antibiotic ointment or cream – used
when bacterial resistance to other drugs is a problem: apply 1/16-inch-thick film
directly to burn
- Mafenide (Sulfamylon) – water soluble cream bacteriostatic gr + - bacteria- apply
1/16 inch directly to burn – notify physician if hyperventilation occurs as this
drug may ppt. metabolic acidosis.
- Silver Sulfadiazine (Silvadene) – cream Broad spectrum to gr+/ -; does not cause
metabolic acidosis – keep burn covered at all times with Sulfadiazine – (1/16 inch
thick);
- Silver Nitrate – Antiseptic solution against gr-, dressings are applied to the burn
and then kept moist with Silver nitrate; used on extensive burns that may
precipitate fluid and electrolyte imbalance.
-
H. DKA (DIABETIC KETOACIDOSIS)
/ HHNS (HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME)
DKA - Is a life-threatening
complication of DM type 1,
develops because of severe insulin
deficiency
MANIFESTATIONS:
1. Hyperglycemia
2. Dehydration
3. Electrolyte loss and acidosis
CAUSES: Missed insulin dose or
infection
HHNS- SIMILAR TO DKA WITH
EXTREME hyperglycemia except
that in HHNS there is no acidosis.
This is for DM type 2
ASSESSMENT:
1. Blood glucose – 300 – 800
mg/dl
2. Low bicarbonate & low pH
3. Dehydration
4. Mental status changes
5. Neurological deficits
6. Seizures
NURSING INTERVENTIONS:
1. Administer Insulin IV push 5-10 units 1st then IV infusion
2. Restore Fluids (administer fluids as prescribed).
- treat dehydration w/ rapid infusion of NSS or .45% saline
- when blood glucose reaches 250300 mg/dl D5NS, or D5 .45%Saline is used
3. Always use infusion pump for IV insulin
4. Monitor serum potassium (initially as a result of acidosis Hyperkalemia is present upon
admin of insulin K+ level drops)
5. Monitor LOC= too rapid decrease in blood glucose may cause cerebral edema

29
 I. THYROID CRISIS – (THROID STORM/ Thyrotoxicosis)
- Acute life-threatening condition that occurs in a client with uncontrollable
hyperthyroidism – maybe a result of manipulation of thyroid gland during surgery
(release of thyroid hormones to bloodstream)
Causes: Undiagnosed, untreated hyperthyroidism, infection, trauma
Medical management:
➢ Antithyroid medications; beta blockers; glucocorticoids & iodides are given before
surgery to prevent thyroid crisis
➢ Antithyroid meds: Iodide, Propylthiouracil, Methimazole Iodides/ Iodine = Reduce the
vascularity of the thyroid gland before thyroidectomy
➢ Iodides= used in the treatment of thyroid storm because it enables the storage of TH in
the thyroid gland. However, it is given only for 10-14 days because eventually it loses its
effect on the thyroid gland.
NURSING INTERVENTION:
1. ASSESSMENT: elevated Temp (high fever); tachycardia; agitation; tremors
2. Maintain a patent airway
3. Administer antithyroid meds as prescribed (sodium iodide solution) Monitor VS

J. MULTI- ORGAN DYSFUNCTION

30
 Criteria for Diagnosis of MODS
a. Cardiovascular Failure presence of 1 or more of the ff:
<54 bpm, Systolic < 60 mm Hg, V Tachycardia / V fibrillation, pH < 7.24
b. Respiratory Failure
RR < 5/min, RR> 49/min
c. Renal Failure presence of 1 or more of the ff:
Output < 479 ml/24 hr. or < 159 ml/ 8 hr., BUN > 100mg/dl, Crea > 3.5mg/dl
d. Hematologic Failure presence of 1 or more of the ff:
WBC < 1000 uL, Platelets < 20,000 HCT < 20%
e. Hepatic failure presence of both of the FF:
Bilirubin > 6 mg %, PT > 4 sec over control in absence of anticoagulation,
(normal PT – 11-12sec)
f. Neurologic Failure GCS < 6 in absence of sedation
Medical Management:
- Control of infection w/ antibiotics (common MRSA & Vancomycin resistant)
- Aggressive pulmonary care mech vent & O2 (intubation)
- Enteral (NGT) feeding
Nursing Management Limited: effective client & family coping
K. AIRWAY OBSTRUCTION

- Acute upper airway obstruction is a life-threatening medical emergency.

- The airway may be partially or completely occluded. If the airway is completely
obstructed, permanent brain damage or death will occur within 3 to 5 minutes secondary
to hypoxia.
- Partial obstruction of the airway can lead to progressive hypoxia, hypercarbia, and
respiratory and cardiac arrest.
- Causes include aspiration of foreign bodies, anaphylaxis, viral or bacterial infection,
trauma, and inhalation or chemical burns.
- In adults, aspiration of a bolus of meat is the most common cause of airway obstruction.
- In children, small toys, buttons, coins, and other objects are commonly aspirated in
addition to food. Peritonsillar abscesses, epiglottitis, and other acute infectious processes
of the posterior pharynx can result in airway obstruction.
Clinical Manifestation:
- choking, apprehensive appearance, inspiratory and expiratory stridor, labored breathing,
use of accessory muscles (suprasternal and intercostal retraction), flaring nostrils,
increasing anxiety, restlessness, and confusion. Cyanosis and loss of consciousness
develop as hypoxia worsens.
- Typically, the victim with a foreign body airway obstruction cannot speak, breathe, or
cough. The patient may clutch the neck between the thumb and fingers (universal distress
signal). The first response is to ask this person whether he or she is choking.
Diagnostics exams:
- X-rays, laryngoscopy, or bronchoscopy also may be performed.

31
Management:
- Establishing an airway may be as simple as repositioning the patient’s head to prevent the
tongue from obstructing the pharynx.
- Alternatively, other maneuvers, such as:
a. abdominal thrusts
b. head-tilt–chin-lift maneuver
c. jaw-thrust maneuver
d. insertion of ENDOTRACHEAL INTUBATION, CRICOTHYROIDOTOMY

L. SHOCK
is a critical physical condition due to failure of the circulatory system to maintain adequate blood
flow in the body and ceases the delivery of oxygen and nutrients to vital organs.

Three stages of shock

➢ THE COMPENSATORY STAGE OF SHOCK
BP normal limits. shunted from the kidney, skin and GIT to the vital organs- brain, liver.
➢ PROGRESSIVE STAGE OF SHOCK
regulate blood pressure can no longer compensate and the mean arterial. The overworked heart
becomes dysfunctional.
➢ IRREVERSIBLE STAGE OF SHOCK
there is severe organ damage that patients do not respond anymore to treatment. Survival is
almost impossible

TYPES OF SHOCK
1. Cardiogenic – Heart stop to pump due to heart disease.
2. Anaphylactic --- Severe allergic Reaction
3. Hypovolemic --- Severe fluid loss
4. Psychogenic --- cause by anxiety, fears, altered adaptation in traumatic experience
32
5. Neurogenic --- cause by spinal fracture or dislocation
6. Metabolic --- loss of body fluids
7. Respiratory ---- air way obstruction and hyperventilation
8. Septic --- severe bacterial infection

SIGNS AND SYMPTOMS

a. Early Stage
- consciousness altered, pallor/cyanosis, cold/clammy skin, shallow and irregular
breathing, rapid and weak pulse, dilated pupil. n - /v, thirst,

b. Late Stage:
- apathetic/unresponsive, decreased blood pressure, decreased temperature. mottled
appearance

TRIAD SYMPTOMS OF SHOCK

- hypotension, tachycardia, tachypnea
-
DRUGS USED TO TREAT SHOCK
➢ Corticosteroids – use in septic shock protect cell membranes and decrease inflammatory
response to stress
➢ Antibiotics –infectious process related to septic shock
➢ Norepinephrine (Levophed)- improves cardiac contractility and cardiac output potent
vasoconstrictor
➢ Dopamine (Intropin) – improves perfusion of the kidneys & urine output
➢ Dobutamine (Dobutrex)- increases myocardial contractility, vasodilator
➢ Digitalis preparation - improves cardiac performance
➢ Isoproterenol (Isuprel)- increases myocardial contractility
➢ Sodium Nitropusside Vasodilator- increases cardiac output, use in cardiogenic shock, and
hypertensive emergency.

Emergency Nursing Management

1. Airway
2. Promote restoration of blood volume; administer fluid and blood replacement as ordered
3. Administer drugs as ordered
4. Minimize factors contributing to shock.
5. Best Position- Modified Trendelenburg

M. WOUNDS
- A bodily injury caused by physical means, with disruption of the normal continuity of
structures.

a. CLOSED WOUND
- Caused by a damage of a tissue with in the layer of the skins and to the layer of the skin
without breaking the continuity of the skin.
1. Contusions (more commonly known as a bruise) caused by blunt force trauma that
damages tissue under the skin.
2. Hematoma- (also called a blood tumor) caused by damage to a blood vessel that in turn
causes blood to collect under the skin.
3. Crushing Injuries - caused by a great or extreme amount of force applied over a long
period of tissue

b. OPEN WOUND
is a break in the continuity of the skin resulting in shedding of blood and
creating a portal of entry for microorganism.
1. Puncture- use by sharp and pointed object
2. Abrasion (grazes)- a superficial wound in which the topmost layer of the skin (the
epidermis) is scraped off.
3. Sucking wound- a penetrating wound of the chest through which air is drawn in and out.
4. Avulsion- the forcible tearing away of a body part by trauma.
5. Laceration- tissues are torn, uneven cut.
33
 6. Incision- one caused by a cutting instrument, clean cut.

EMERGENCY CARE PROCEDURES:

1. Wash the wound
2. Control bleeding
3. Cover the wound
4. Look for drop BP and TEMP.

- Bruises, strains, sprains, dislocations.

R – rest (20-30 min q 2 – 3 hrs. in 1st 24 – 48 hrs.)
I – ice application (10 – 15 min.)
C --compression (direct pressure)
E – elevation (above the heart )
- Amputation
Control Bleeding
Find the severed part Seek Immediate medical attention.
- Chest Injuries
Check ABC
Stabilize Chest using pillow, coat or blanket.
Seek medical attention
Do not remove impaled object.
- Eye injuries
Protect injured eye
Patch unaffected eye
Do not remove object stuck on the eye
Do not apply hard pressure

N. CHRONIC OBSTRUCTIVE
PULMONARY DISEASE

- Is a disease state characterized by

airflow obstruction caused by
emphysema or chronic bronchitis.
- Progressive airflow limitation
occurs, associated with an
abnormal inflammatory response
of the lungs that is not completely
reversible.
- COPD leads to pulmonary
insufficiency, pulmonary
hypertension, and cor pulmonale.
- The most important risk factor for
COPD is cigarette smoking. Pipe,
cigar, and other types of tobacco
smoking are also risk factors

34
 - A host risk factor for COPD is a deficiency of alpha1 antitrypsin, an enzyme inhibitor
that protects the lung parenchyma from injury.

Interventions
➢ Monitor vital signs.
➢ Administer a concentration of oxygen based on ABG
values and oxygen saturation by pulse oximetry as
prescribed.
➢ Monitor pulse oximetry.
➢ Provide respiratory treatments and CPT.
➢ Instruct the client in diaphragmatic or abdominal
breathing techniques and pursed-lip breathing
techniques, which increase airway pressure and keep
air passages open, promoting maximal carbon
dioxide expiration.
➢ Record the color, amount, and consistency of sputum.
➢ Suction the client’s lungs, if necessary, to clear the
airway and prevent infection.
➢ Monitor weight.
➢ Encourage small, frequent meals to maintain nutrition
and prevent dyspnea.

35
 ➢ Provide a high-calorie, high-protein diet with supplements.
➢ Encourage fluid intake up to 3000 mL/day to keep
secretions thin, unless contraindicated.
➢ Place the client in a Fowler’s position and leaning
forward to aid in breathing
➢ Allow activity as tolerated.
➢ Administer bronchodilators as prescribed, and instruct the client in the use of oral and
inhalant medications.
➢ Administer corticosteroids as prescribed for exacerbations.
➢ Administer mucolytics as prescribed to thin secretions.
➢ Administer antibiotics for infection if prescribed

O. ASTHMA
- Chronic inflammatory disorder of the airways that causes varying degrees of
obstruction in the airways 2.
- Marked by airway inflammation and hyperresponsiveness to a variety of stimuli or
- Status asthmaticus is a severe life-threatening asthma episode that is refractory to
treatment and may result in pneumothorax, acute cor pulmonale, or respiratory arrest.

Assessment:
1. Restlessness
2. Wheezing or crackles
3. Use of accessory muscles for breathing
4. Tachypnea with hyperventilation
5. Prolonged exhalation
6. Tachycardia
7. Decreased oxygen saturation
Nursing Interventions During an Acute Asthma Episode
➢ Position the client in a high Fowler’s position or sitting to aid in breathing.
➢ Administer oxygen as prescribed.
➢ Stay with the client to decrease anxiety.
➢ Administer bronchodilators as prescribed.
➢ Record the color, amount, and consistency of sputum, if any.
➢ Administer corticosteroids as prescribed. Auscultate lung sounds before, during, and after
treatments

36
 P. ACUTE RESPIRATORY DISTRESS SYNDROME
- it is caused by a diffuse lung injury and leads to extravascular lung fluid. The major
site of injury is the alveolar capillary membrane.
- The interstitial edema causes compression and obliteration of the terminal airways
and leads to reduced lung volume and compliance.
- The ABG levels identify respiratory acidosis and hypoxemia that do not respond to
an increased percentage of oxygen.
- The chest x-ray shows bilateral interstitial and alveolar infiltrates; interstitial edema
may not be noteduntilthereisa30%increaseinfluidcontent
- Causes include sepsis, fluid overload, shock, trauma, neurological injuries, burns,
DIC, drug ingestion, aspiration, and inhalation of toxic substances.
Assessment
1. Tachypnea
2. Dyspnea
3. Decreased breath sounds
4. Deteriorating ABG levels
5. Hypoxemia despite high concentrations of delivered oxygen
6. Decreased pulmonary compliance
7. Pulmonary infiltrates
Interventions
➢ Identify and treat the cause of the acute respiratory distress syndrome.
➢ Administer oxygen as prescribed.
➢ Place the client in a Fowler’s position.
➢ Restrict fluid intake as prescribed.
➢ Provide respiratory treatments as prescribed.
➢ Administer diuretics, anticoagulants, or corticosteroids as prescribed.
➢ Prepare the client for intubation and mechanical ventilation using PEEP.

MECHANICAL VENTILATOR
Types
1. Pressure-cycled ventilator: The ventilator pushes air into the lungs until a specific airway
pressure is reached; it is used for short periods, as in the post anesthesia care unit.
2. Time-cycled ventilator: The ventilator pushes air in to the lungs until a preset time has
elapsed; it is used for the pediatric or neonatal client.
3. Volume-cycled ventilator
a. The ventilator pushes air into the lungs until a preset volume is delivered.
b. A constant tidal volume is delivered regardless of the changing compliance of the
lungs and chest wall or the airway resistance in the client or ventilator.
4. Microprocessor ventilator
a. A computer or microprocessor is built into the ventilator to allow continuous
monitoring of ventilatory functions, alarms, and client parameters.
b. This type of ventilator is more responsive to clients who have severe lung disease or
require prolonged weaning.

37
Modes of ventilation
1. Noninvasive positive pressure ventilation or BiPAP
a. Ventilatory support given without using an invasive
artificial airway (endotracheal tube or tracheostomy tube);
orofacial masks and nasal masks are used instead.
b. An inspiratory positive airway pressure(IPAP) and an
expiratory positive airway pressure (EPAP) are set on a
large ventilator or a small flow generator ventilator with a
desired pressure support and positive end-expiratory
pressure (PEEP) level. This allows more air to move into
and out of the lungs without the normal muscular activity
needed to do so.
c. Can be used in certain situations of COPD distress,
heart failure, asthma, pulmonary edema, and hypercapnic
respiratory failure
Note: A resuscitation bag should be available at the
bedside for all clients receiving mechanical ventilation.
2. Controlled
a. The client receives a set tidal volume at a set rate.
b. Used for clients who cannot initiate respiratory effort.
c. Least used mode; if the client attempts to initiate a
breath, the ventilator locks out the client’s inspiratory effort.
3. Assist-control
a. Most commonly used mode
b. Tidal volume and ventilatory rate are preset on the
ventilator.
c. The ventilator takes over the work of breathing for the
client.
d. The ventilator is programmed to respond to the client’s
inspiratory effort if the client does initiate a breath.
e. The ventilator delivers the preset tidal volume when the
client initiates a breath while allowing the client to control
the rate of breathing.
f. If the client’s spontaneous ventilatory rate increases, the
ventilator continues to deliver a preset tidal volume with
each breath, which may cause hyperventilation and
respiratory alkalosis

4. Synchronized intermittent mandatory ventilation (SIMV)

a. Similar to assist-control ventilation in that the tidal volume
and ventilatory rate are preset on the ventilator
b. Allows the client to breathe spontaneously at her or his own
rate and tidal volume between the ventilator breaths
c. Can be used as a primary ventilatory mode or as a weaning
mode
d. When SIMV is used as a weaning mode, the number of
SIMV breaths is decreased gradually, and the client gradually
resumes spontaneous breathing.

38
Interventions
➢ Assess the need for suctioning and observe the type, color, and amount of secretions.
➢ Assess ventilator settings.
➢ Assess the level of water in the humidifier and the temperature of the humidification system
because extremes in temperature can damage the mucosa in the airway.
➢ Ensure that the alarms are set.
➢ If a cause for an alarm cannot be determined, ventilate the client manually with a
resuscitation bag until the problem is corrected.
➢ Empty the ventilator tubing when moisture collects.
➢ Turn the client at least every 2 hours or get the client out of bed, as prescribed, to prevent
complications of immobility.
➢ Have resuscitation equipment available at the bedside.
Weaning: Process of going from ventilator dependence to spontaneous breathing
1. SIMV
a. The client breathes between the preset breaths per minute rate of the ventilator.
b. The SIM V rate is decreased gradually until the client is breathing on his or her own
without the use of the ventilator.

2. T-piece
a. The client is taken off the ventilator and the ventilator is replaced with a T-piece or
CPAP, which delivers humidified oxygen.
b. The client is taken off the ventilator for short periods initially and allowed to breathe
spontaneously.
c. Weaning progresses as the client is able to tolerate progressively longer periods off the
ventilator.

3. Pressure support
a. Pressure support is a predetermined pressure set on the ventilator to assist the client in
respiratory effort.
b. As weaning continues, the amount of pressure is decreased gradually.
c. With pressure support, pressure may be maintained while the preset breaths per minute
of the ventilator are decreased gradually.

39
 Q. CIRRHOSIS
- A chronic, progressive disease of the liver characterized by diffuse degeneration and
destruction of hepatocytes Repeated destruction of hepatic cells causes the formation of
scar tissue
- Cirrhosis has many causes and is due to chronic damage and injury to liver cells; the most
common are chronic hepatitis C, alcoholism, nonalcoholic fatty liver disease (NAFLD),
and nonalcoholic steatohepatitis (NASH).

COMPLICATIONS

1. Portal hypertension: A persistent increase in pressure

in the portal vein that develops as a result of
obstruction to flow

2. Ascites
a. Accumulation of fluid in the peritoneal cavity that
results from venous congestion of the hepatic
capillaries b.
b. Capillary congestion leads to plasma leaking
directly from the liver surface and portal vein.

3. Bleeding esophageal varices: Fragile, thin-walled,

distended esophageal veins that become irritated and
rupture

4. Coagulation defects
a. Decreased synthesis of bile fats in the liver
prevents the absorption of fat-soluble vitamins.
b. Without vitamin K and clotting factors II, VII, IX,
and X, the client is prone to bleeding.

5. Jaundice: Occurs because the liver is unable to

metabolize bilirubin and because the edema, fibrosis,
and scarring of the hepatic bile ducts interfere with
normal bile and bilirubin secretion

6. Portal systemic encephalopathy: End-stage hepatic failure characterized by altered level

of consciousness, neurological symptoms, impaired thinking, and neuromuscular
disturbances; caused by failure of the diseased liver to detoxify neurotoxic agents such as
ammonia

7. Hepatorenal syndrome
a. Progressive renal failure associated with hepatic failure
b. Characterized by a sudden decrease in urinary output, elevated blood urea nitrogen and
creatinine levels, decreased urine sodium excretion, and increased urine osmolarity

40
ASSESSMENT

INTERVENTIONS
➢ Elevate the head of the bed to minimize shortness of breath.
➢ If ascites and edema are absent and the client does not exhibit signs of impending coma, a
high-protein diet supplemented with vitamins is prescribed.
➢ Provide supplemental vitamins (B complex; vitamins A, C, and K; folic acid; and
thiamine) as prescribed.
➢ Restrict sodium intake and fluid intake as prescribed.
➢ Initiate enteral feedings or parenteral nutrition as prescribed.
➢ Administer diuretics as prescribed to treat ascites.
➢ Monitor intake and output and electrolyte balance.
➢ Weigh client and measure abdominal girth daily
➢ Monitor level of consciousness; assess for precoma state (tremors, delirium).
➢ Monitor for asterixis, a coarse tremor characterized by rapid, non- rhythmic extensions
and flexions in the wrist and fingers
➢ Monitor for fetor hepaticus, the fruity, musty breath odor of severe chronic liver disease.
➢ Maintain gastric intubation to assess bleeding or esophagogastric balloon tamponade to
control bleeding varices if prescribed.
➢ Administer blood products as prescribed.
➢ Monitor coagulation laboratory results; administer vitamin K if prescribed.
➢ Administer antacids as prescribed.
➢ Administer lactulose as prescribed, which decreases the pH of the bowel, decreases
production of ammonia by bacteria in the bowel, and facilitates the excretion of
ammonia.
➢ Administer antibiotics (Neomycin Sulfate) as prescribed to inhibit protein synthesis in
bacteria and decrease the production of ammonia.
➢ Avoid medications such as opioids, sedatives, and barbiturates and any hepatotoxic
medications or substances.
➢ Instruct the client about the importance of abstinence of alcohol intake.
➢ Prepare the client for paracentesis to remove abdominal fluid.
➢ Prepare the client for surgical shunting procedures if prescribed to divert fluid from
ascites into the venous system.

41
 R. ESOPHAGEAL VARICES
- Dilated and tortuous veins in the submucosa of the esophagus.
- Caused by portal hypertension, often associated with liver cirrhosis; are at high risk for
rupture if portal circulation pressure rises
- Bleeding varices are an emergency.
- The goal of treatment is to control bleeding, prevent complications, and prevent the
recurrence of bleeding.
ASSESSMENT
1. Hematemesis
2. Melena
3. Ascites
4. Jaundice
5. Hepatomegaly and splenomegaly
6. Dilated abdominal veins
7. Signs of shock
Note: Rupture and resultant hemorrhage of esophageal varices is the primary concern because it
is a life- threatening situation.
INTERVENTION

42
43
 S. POISONING
- A poison is any substance that, when ingested, inhaled, absorbed, applied to the skin,
or produced within the body in relatively small amounts, injures the body by its
chemical action.
1. INGESTED (SWALLOWED) POISONS
- Swallowed poisons may be corrosive. Corrosive poisons include alkaline and acid
agents that can cause tissue destruction after coming in contact with mucous
membranes. Alkaline products include lye, drain cleaners, toilet bowl cleaners,
bleach, non-phosphate detergents, oven cleaners, and button batteries (batteries used
to power watches, calculators, or cameras).
- Acid products include toilet bowl cleaners, pool cleaners, metal cleaners, rust
removers, battery acid.
Management
➢ The patient who has ingested a corrosive poison is given water or milk to drink
for dilution. However, dilution is not attempted if the patient has acute airway
edema or obstruction or if there is clinical evidence of esophageal, gastric, or
intestinal burn or perforation. The following gastric emptying procedures may be
used as prescribed:
a. Syrup of ipecac to induce vomiting in the alert patient. •
b. Gastric lavage for the obtunded patient
c. Gastric aspirate is saved and sent to the laboratory for testing
d. Activated charcoal administration if poison is one that is absorbed by charcoal
Note: Vomiting is never induced after ingestion of caustic substances (acid or alkaline) or
petroleum distillates
2. INHALED POISONS: CARBON MONOXIDE POISONING
- Carbon monoxide poisoning may occur as a result of industrial or household incidents
or attempted suicide. It is implicated in more deaths than any other toxin except
alcohol.
- Carbon monoxide exerts its toxic effect by binding to circulating hemoglobin and
thereby reducing the oxygen-carrying capacity of the blood. Hemoglobin absorbs
carbon monoxide 200 times more readily than it absorbs oxygen. Carbon monoxide–
bound hemoglobin, called carboxyhemoglobin, does not transport oxygen.
- A person suffering from carbon monoxide poisoning may appear intoxicated (from
cerebral hypoxia).
- Other signs and symptoms include headache, muscular weakness, palpitation,
dizziness, and confusion, which can progress rapidly to coma. Skin color, which can
range from pink or cherry-red to cyanotic and pale, is not a reliable sign. Pulse
oximetry is also not valid, because the hemoglobin is well saturated.
Management
➢ Carry the patient to fresh air immediately; open all doors and windows.
➢ Loosen all tight clothing.
➢ Initiate cardiopulmonary resuscitation if required; administer oxygen.
➢ Prevent chilling; wrap the patient in blankets.
➢ Keep the patient as quiet as possible.
➢ Do not give alcohol in any form.
➢ Oxygen is administered until the carboxyhemoglobin level is less than 5%.

44
 3. SKIN CONTAMINATION POISONING (CHEMICAL BURNS)
- Skin contamination injuries from exposure to chemicals are challenging because of
the large number of offending agents with diverse actions and metabolic effects. The
severity of a chemical burn is determined by the mechanism of action, the penetrating
strength and concentration, and the amount and duration of exposure of the skin to the
chemical.
- The skin should be drenched immediately with running water from a shower, hose, or
faucet.
- Water should not be applied to burns from lye or white phosphorus because of the
potential for an explosion or for deepening of the burn. All evidence of these
chemicals should be brushed off the patient before any flushing.!
- The standard burn treatment appropriate for the size and location of the wound
(antimicrobial treatment, debridement, tetanus prophylaxis as prescribed) is
instituted. The patient may require plastic surgery for further wound management.

T. SUBSTANCE ABUSE

1. ACUTE ALCOHOL INTOXICATION

- Alcohol, or ethanol, is a direct multisystem toxin and CNS depressant that causes
drowsiness, incoordination, slurring of speech, sudden mood changes, aggression,
belligerence, grandiosity, and uninhibited behavior. In excess, it also can cause
stupor, coma, and death.
- Signs include head injury, hypoglycemia (which mimics intoxication), and other
health problems.
- Alcohol withdrawal syndrome (AWS) is an acute toxic state that occurs as a result
of sudden cessation of alcohol intake after a bout of heavy drinking or, more usually,
after prolonged intake of alcohol.
- AWS show signs of anxiety, uncontrollable fear, tremor, irritability, agitation,
insomnia, and incontinence. They are talkative and preoccupied and experience
visual, tactile, olfactory, and auditory hallucinations that often are terrifying.
Autonomic overactivity occurs and is evidenced by tachycardia, dilated pupils, and
profuse perspiration. Usually, all vital signs are elevated in the alcoholic toxic state.
Management
➢ Usually, the patient is sedated as directed with a sufficient dosage of benzodiazepines to
establish and maintain sedation, which reduces agitation, prevents exhaustion, prevents
seizures, and promotes sleep. Examples, chlordiazepoxide [Librium], lorazepam, and
clonidine). Haloperidol or droperidol may be administered for severe acute AWS.
➢ The patient is placed in a calm, non-stressful environment (usually a private room) and
observed closely. The room remains lighted to minimize the potential for illusions and
hallucinations. Homicidal or suicidal responses may result from hallucinations.
➢ Temperature, pulse, respiration, and blood pressure are recorded frequently (every 30
minutes in severe forms of delirium) in anticipation of peripheral circulatory collapse or
hyperthermia (the two most lethal complications). Phenytoin (Dilantin) or other
antiseizure medications may be prescribed to prevent or control repeated withdrawal
seizures.
➢ Hypoglycemia may accompany alcohol withdrawal, because alcohol depletes liver
glycogen stores and impairs gluconeogenesis; many patients with alcoholism also are
malnourished. Parenteral dextrose may be prescribed if the liver glycogen level is
depleted. Orange juice, Gatorade, or other forms of carbohydrates are given to stabilize
the blood glucose level and counteract tremulousness. Supplemental vitamin therapy and
a high-protein diet are provided as prescribed to counteract vitamin deficiency

45
2. DRUGS
a. Narcotics
b. Barbiturates
c. Amphetamines
d. Hallucinogens
e. Sedatives
f. Salicylate
g. Acetaminophen
h. TCA

46
47
V. EMERGENCY DRUGS
1. ACTIVATED CHARCOAL
Class: Absorbent
Actions: Absorbs toxins by binding to them to prevent GI absorption.
Indications: Adsorbent used in overdoses and poisonings, if emesis is not indicated.

2. ADENOSINE
Class: Antiarrhythmic
Actions: Slows conduction through the AV node.
Indications: Unstable Narrow-QRS Tachycardia refractory to vagal maneuvers 1. Chest
pain, systolic BP < 90, decreased LOC, or CHF 2. Rate 150/min. (adult), 220
(children) 3. Regular rhythm 4. QRS < 0.12 seconds

3. ALBUTEROL
Class: Sympathomimetic (B2 selective)
Actions: Bronchodilation
Indications: Asthma, Emphysema, COPD, Anaphylactic respiratory distress

4. AMIODARONE
Class: Antiarrhythmic
Actions: Depresses automaticity of SA node. Slows conduction & increases
refractoriness of the AV node. Increases Atrial & Ventricular refractoriness
Indications: Pulseless VF / VT, V-tach with pulse, Wide complex Tachycardia

5. AMYL NITRITE
Class: Inhalant
Actions: Amyl Nitrate has affinity for cyanide ions; reacts with hemoglobin to form
methemoglobin.
Indications: Cyanide or hydrocyanic poisoning

6. ACETYLSALICYLIC ACID, Aspirin

Class: Analgesic, antipyretic
Actions: Blocks platelet aggregation
Indications: Chest pain suggestive of new AMI

7. ATIVAN (Lorazepam)
Class: Tranquilizer, Anti-convulsant and Skeletal muscle relaxant.
Actions: Binds specifically to sites in the brain acting to inhibit the chaotic
neurotransmission seen in seizures.
Indications: 1. Status seizures 2. As an amnesic / anxiolytic prior to cardioversion 3.
Chemical restraint

8. ATROPINE SULFATE
Class: Parasympatholytic (anticholinergic)
Actions: Blocks acetylcholine receptors (decreases vagal tone thus increasing heart rate)
Indications: 1. Narrow-QRS (< 0.12 sec) Bradycardia with systolic BP < 90, decreased
LOC, chest pain, or PVC’s 2. Asystole 3. Narrow-QRS (< 0.12 sec) PEA with rate <
60/min. 4. Severe organophosphate (insecticide) poisoning

9. ATROVENT (Ipratropium Bromide)

Class: Anticholinergic
Actions: Inhibits interaction of acetylcholine at receptor sites of the bronchial smooth
muscle resulting in bronchial dilation.
Indications: For Relief of Bronchospasms in those with COPD

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10. CALCIUM GLUCONATE
Class: Membrane stabilizer and antidote
Actions: Calcium is the most common cation in the human body and the majority of the
body stores are located in bone. It is critical in many different cellular processes and is
essential for the functional integrity of muscle (skeletal, smooth and cardiac) and nervous
tissues.
Indications: 1. As a membrane stabilizer in suspected hyperkalemia. Reverses EKG
changes pending correction of the extracellular potassium concentration. 2. As a potential
antidote in suspected calcium channel blocker overdoses, hydrofluoric acid poisoning and
iatrogenic magnesium intoxication.

11. CAPTOPRIL (Capoten)

Class: Ace Inhibitor
Actions: Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor.
Decreases peripheral arterial resistance so there is reduced sodium and water retention
and lowers blood pressure. Onset occurs in 15-30 minutes. Persist for 6-12 hours.
Indications: 1. Flash pulmonary Edema 2. CHF

12. CLONIDINE (Catapres)

Class: centrally acting alpha-agonist hypotensive agent
Indication: hypertension

13. DEXAMETHASONE (Decadron)

Class: Corticosteroid
Actions: Dexamethasone is a synthetic steroid that suppresses acute and chronic
inflammation. In addition, it potentiates vascular smooth muscle relaxation by beta-
adrenergic agonists and may alter airway hyperactivity.
Indications: Moderate to severe asthma/COPD. Severe allergic reactions. Croup

14. DEXTROSE 50%

Class: Carbohydrate
Actions: Elevates blood glucose level
Indications: 1. GCS 12 2. Rapid glucose determination < 70 mg/dl 3. Rapid glucose
determination – Stroke Patient < 60 mg/dl 4. Seizures lasting > 3 minutes

15. DIPHENHYDRAMINE
Class: Antihistamine
Actions: 1. Blocks histamine receptors 2. Has an antiemetic effect
Indications: 1. Second Line for Anaphylaxis 2. Dystonic reactions to antipsychotic drugs.

16. DOBUTAMINE
Class: It is a synthetic catecholamine.
Indications: inotropic support in the short-term treatment of adults with cardiac
decompensation due to depressed contractility resulting either from organic heart disease
or from cardiac surgical procedures.

17. DOPAMINE HCL, (Intropin)

Class: Sympathomimetic
Actions: 1. Increases cardiac contractility 2. Causes peripheral vasoconstriction
3. Increases chronotropic and inotropic effects
Indications: Non-hypovolemic shock

18. EPINEPHRINE 1:1,000

Class: Sympathomimetic
Actions: 1. Vasoconstriction: improves coronary blood flow and supports BP in
anaphylactic shock. 2.Inotropic and chronotropic effects. 3. Bronchodilation.
49
 Indications: 1. Anaphylaxis 2. Pediatric cardiac arrest (see Epinephrine 1:10,000) 3.
Bronchial asthma 4. Stridor & lower airway wheezing not broken by albuterol 5. ACLS
applications (VF, pulseless VT, Asystole, PEA)

19. FENTANYL
Class: Narcotic Analgesic
Actions: Acts on the opiate receptors in the brain to block the sensation of pain 1.
Approximately 80 times more potent than Morphine 2. No prominent hemodynamic
changes 3. Has sedative effects 4. Duration of action 30 – 60 min, Onset 2 – 3 min
Indications: 1. Allergy to Morphine or as 1st line analgesic with the following: 2.
Traumatic injuries with severe pain; (i.e., orthopedic injuries.) 3. Non traumatic pain;
(i.e., cancer, abdominal pain., kidney stones.) 4. Pain from Burns 5. Analgesic of choice
in pediatrics

20. FUROSEMIDE, (Lasix)

Class: Diuretic
Actions: 1. Inhibits reabsorption of NaCl 2. Promotes prompt diuresis 3. Vasodilatation
Indications: Pulmonary edema with signs and symptoms of volume overload ( recent
weight gain, peripheral edema, JVD).

21. GLUCAGON HCL

Class: Hormone (Anti-hypoglycemic agent)
Actions: 1. Causes breakdown of glycogen to glucose 2. Elevates blood glucose level
Indications: Unable to administer IV D50 in: 1. GCS < 12 2. Rapid glucose determination
< 70 mg/dl. 3. Rapid glucose determination suspected stroke pt.< 60 mg/dl 4. Seizure
lasting> 3 min.

22. HYDROCORTISONE
Class: corticosteroid/ anti-inflammatory
Indication: To treat or prevent allergic reactions, autoimmune diseases, skin conditions,
asthma and other lung conditions.

23. HYOSCINE BUTYL BROMIDE (Buscopan)

Class: antispasmodics
Action: relieve smooth muscle spasms (cramps) in the stomach and intestines and in the
bladder and urethra

24. ISOSORBIDE DINITRATE (ISORDIL)

Class: organic nitrates are vasodilators
Indication: for the prevention of angina pectoris due to coronary artery disease

25. IPECAC SYRUP

Class: Emetic
Indication: Poisoning

26. KETOROLAC
Class: nonsteroidal anti-inflammatory drug (NSAID)
Indication: moderate to severe pain

27. LIDOCAINE HCL

Class: Antiarrhythmic
Actions: 1. Suppresses ventricular ectopy 2. Elevates threshold of ventricular fibrillation
3. Decreases ventricular automaticity
Indications: 1. V-Fib and V-Tach 2. Prevention of V-Fib and V-Tach 3. Numbing
solution of bone marrow after conscious IO insertion
50
 LIDOCAINE PRE-MIX
Class: Antiarrhythmic
Actions: 1. Suppress ventricular ectopy after RSC. 2. Elevates threshold of ventricular
fibrillation. 3. Decreases ventricular automaticity.
Indications: 1. Control of V-Fib & V-tach after RSC. 2. Prevention of V-Fib & V-tach
after RSC.

28. MANNITOL
Class: obligatory osmotic diuretic
Indications: 1. Promotion of diuresis in the prevention or treatment of the oliguric phase
of acute renal failure before irreversible renal failure becomes established.
2. Reduction of intracranial pressure and brain mass.
3. Reduction of high intraocular pressure when the pressure cannot be lowered by other
means. 4. Promotion of urinary excretion of toxic materials.

29. MAGNESIUM SULFATE 50%

Class: Anticonvulsant
Actions: 1. CNS depressant 2. Anticonvulsant 3. Smooth muscle relaxant (vasodilation,
bronchodilation)
Indications: 1. Refractory V-Fib and Pulseless V-Tach 2. Eclampsia 3. Torsades de
Pointes 4. Asthma with increasing ETCO2, shark fin tracing and neb tx not working

30. MIDAZOLAM HCL (Versed)

Class: Sedative, hypnotic (Benzodiazepine)
Actions: Sedation by direct action on CNS
Indications: 1. Seizures not caused by hypoglycemia 2. Sedation for cardioversion, TCP.
3. Sedation for RSI. 4. Severe agitation, tachycardia, or hallucinations cause by alcohol
intoxication/withdraw 5. Seizures, tachydysrhythmias, altered vital signs from cocaine or
Methamphetamine overdose. 6. Sedation

31. MORPHINE SULFATE

Class: Narcotic Analgesic
Actions: Acts on the opiate receptors in the brain to block the sensation of pain: CNS
depressant Narcotic analgesic Vasodilation
Indications: 1. Pain associated with acute MI 2. Acute pain, such as isolated extremity
trauma/orthopedic injuries. 3. Back Spasms 4. Pain from burns 5. Cancer 6. Non-
traumatic abdominal pain.

32. NIFEDIPINE
Class: calcium channel blockers
Action: It works by relaxing the muscles of your heart and blood vessels.
Indication: hypertension (high blood pressure) and angina (chest pain).

33. NALOXONE, (Narcan)

Class: Narcotic Antagonist
Actions: Reverses effects of narcotics by competing for opiate receptors.
Indications: Respiratory depression or systolic BP < 90 in a narcotic overdose. Rule out
narcotic OD in coma of unknown etiology

34. NITROGLYCERIN, Nitrostat

Class: Coronary Vasodilator
Actions: Smooth muscle relaxant (vasodilator) Reduces peripheral resistance; reduces
cardiac work
Indications: Chest pain (cardiac cause suspected) Pulmonary Edema

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35. NUBAIN
Class: Synthetic opioid- antagonist
Actions: 1. CNS depressant 2. Narcotic analgesic 3. Vasodilation
Indications: Use in place of Morphine when patent is allergic to Morphine or you are a
long distance from your MS supply

36. OMEPRAZOLE
Class: proton pump inhibitors (PPIs)
Indications: gastric or duodenal ulcers, gastroesophageal reflux disease (GERD), erosive
esophagitis, and hypersecretory conditions

37. OXYTOCIN (Pitocin)

Class: Hormone
Actions: Increases electrical and contractile activity in uterine smooth muscle.
Oxytocin can initiate or enhance rhythmic contractions at any time during pregnancy, but
the uterus is most sensitive at term.
Indications: 1. Labor augmentation (in-hospital only) 2. Control of post-partum
hemorrhage. Use only by direct physician order

38. PHENERGAN (Promethazine)

Class: Antiemetic
Actions: Competes with histamine for Hi-receptor sites on effector cells.
Indications: 1. Second line antiemetic, may be used 10 – 15 min. after use of Zofran and
no improvement. 2. Treatment of Nausea and Vomiting (Unrelated to Head Injury)

39. POTASSIUM CHLORIDE

Class: Electrolyte Supplements, Parenteral; Electrolytes
Indications: Hypokalemia

40. RANITIDINE
Class: histamine-2 blockers.
Indications: ulcers in the stomach and intestines, Zollinger-Ellison syndrome,
gastroesophageal reflux disease (GERD)

41. SODIUM BICARBONATE

Class: Alkalizing agent
Actions: Buffers metabolic acidosis, neutralizes excess acids in the blood Increases pH
Indications: Cardiac arrest early in dialysis Patients Known metabolic acidosis Cardiac
arrest in a dialysis patient (hyperkalemia). Tricyclic antidepressant overdose

42. SUCCINYLCHOLINE (Anectine)

Class: Skeletal muscle relaxant
Actions: Short acting, motor nerve depolarizing, skeletal muscle relaxant
Indications: To achieve temporary paralysis where endotracheal intubation is indicated,
and where muscle tone or seizure activity prevent it.

43. THIAMINE
Class: B1 Vitamin
Actions: Replace or supplement vitamin B1
Indications: 1. In suspected alcoholics before or after the administration of 50% dextrose.
2. In suspected Wernicke’s or Korsakoff’s syndrome. 3. In malnourished patients.

44. TRAMADOL
Class: opioid (narcotic) analgesics
Indication: relieve moderate to moderately severe pain

52
 45. VASOPRESSIN
Class: Vasopressor
Actions: Vasopressin is a non-peptide hormone made in the posterior pituitary. Its
primary role is water regulation with secondary role of vasoconstriction. It increases GI
and uterine motility, platelet aggregation, and results in secretion of ACTH, aldosterone,
factor VIII. Vasopressin IV/IO is rapidly distributed. No dosage adjustments are needed
for patients with renal, liver, heart failure, or advanced age.
Indications: V-Fib/Pulseless VT, Asystole, PEA

VIII. NORMAL LABORATORY VALUES

53
VII. COMMON MEDICAL ABBREVIATIONS

ADH: antidiuretic hormone

ADL: activities of daily living
AF: atrial fibrillation
AFB: acid-fast bacillus
AIDS: acquired immune deficiency syndrome
AKA: above the knee amputation
ALL: acute lymphocytic leukemia or acute lymphoblastic leukemia
ALOC: altered level of consciousness
ALS: amyotrophic lateral sclerosis
AMI: acute myocardial infarction or anterior myocardial infarction
ARDS: acute respiratory distress syndrome or adult respiratory distress syndrome
AS: aortic stenosis
ASA: aspirin or acetyl salicylic acid
ASD: atrial septal defect
ASHD: arteriosclerotic heart disease
AST: aspartate aminotransferase
AV: atrio-ventricular or arterio-venous
BKA: below the knee amputation
BM: bowel movement
BMR: basal metabolic rate
BPH: benign prostatic hypertrophy
BR: bedrest
BRP: bathroom privileges
BSA: body surface area
BSE: breast self-examination
BSO: bilateral salpingo-oophorectomy
BUN: blood urea nitrogen
C&S: culture and sensitivity

54
CABG: coronary artery bypass graft
CAD: coronary artery disease cap: capsule
CAPD: continuous ambulatory peritoneal dialysis
CAT: computed axial tomography
CBC: complete blood count
CBI: continuous bladder irrigation
CBR: complete bedrest cc:
CEA: carcinoembryonic antigen
CHF: congestive heart
CKD: chronic kidney disease
COPD : chronic obstructive pulmonary disease
CPK: creatinine phosphokinase
CPR: cardiopulmonary resuscitation
CSF: cerebrospinal fluid
CT: computed tomography or chest tube
CVA: cerebrovascular accident or costovertebral angle
CVP: central venous pressure
CXR: chest x-ray dc;
D&C: dilation and curettage
DIC: disseminated intravascular coagulation
DKA: diabetic ketoacidosis dl: deciliter
DM: diabetes mellitus or diastolic murmur
DNR: do not resuscitate
DOE: dyspnea on exertion
DTR: deep tendon reflex or deep tendon reflexes
DVT: deep vein thrombosis
EKG: electrocardiogram
ECT: electroconvulsive therapy
EEG: electroencephalogram
EGD: esophagogastroduodenoscopy
EMG: electromyogram
ENT: ear, nose and throat
ESR: erythrocyte sedimentation rate
ESRD: end-stage renal disease
ESRF: end-stage renal failure
FHR: fetal heart rate
Fx: fracture or fractional urine test
GERD: gastroesophageal reflux disease
GSW: gunshot wound
gtt: drop or drops
GTT: glucose tolerance test
GU: genitourinary
GYN; Gyn: gynecological
H/A: headache
H/H: hemoglobin and hematocrit
Hgb: hemoglobin
HBAg: hepatitis B antigen
HCO3-: bicarbonate
HEENT: head, eyes, ears, nose and throat
HD: hemodialysis
HHNS: hyperglycemic hyperosmolar nonketotic syndrome
HIV: human immunodeficiency virus h
I&D: incision and drainage
I&O: intake and output
ICP: intracranial pressure
ID: intradermal
Ig: immunoglobulin
IM: intramuscular
INR: International Normalized Ratio
IOP: intraocular pressure
55
IPPB: intermittent positive pressure breathing
IVP: intravenous push or intravenous pyelogram
JVD: jugular vein distention or jugular venous distention
K+: potassium
KUB: kidney, ureters, bladder
KVO; kvo: keep vein open
LDH: lactic dehydrogenase
LLL: left lower lobe
LLQ: left lower quadrant
LMP: last menstrual period
LOC: level of consciousness
LP: lumbar puncture
MAP: mean arterial pressure
Mg: magnesium
MI: myocardial infarction
MR: mitral regurgitation
MRI: magnetic resonance imaging
MRSA: methicillin resistant staph aureus
MS: multiple sclerosis or mitral stenosis
MVA: motor vehicle accident
MVC: motor vehicle crash
NGT: nasogastric tube
NICU: Neonatal Intensive Care Unit
NPO: nothing by mouth
NS: normal saline
NSAIDS: nonsteroidal anti-inflammatory drugs
NSR: normal sinus rhythm
ORIF: open reduction and internal fixation
PCA: patient-controlled analgesia
PEEP: positive end expiratory pressure
PEG: percutaneous endoscopic gastrostomy
PERRLA: pupils equal, round, reactive to light and accommodation
PID: pelvic inflammatory disease
PMI: point of maximum impulse or point of maximal impulse
PND: paroxysmal nocturnal dyspnea
po: by mouth
PPD: purified protein derivative
PRN: as needed
PSA: prostate specific antigen
PT: prothrombin time
PTCA: percutaneous transluminal coronary angioplasty
PTT: partial thromboplastin time
PUD: peptic ulcer disease
PVC: premature ventricular contraction
PVD: peripheral vascular disease
q: every or each
qid: four times a day
RA: rheumatoid arthritis or right atrium
RBC: red blood cell
RLL: right lower lobe
RLQ: right lower quadrant
R/O: rule out
ROM: range of motion or rupture of membranes
SBO: small bowel obstruction
SGOT: serum glutamic oxaloacetic transaminase
SL; sl: sublingual
SLE: systemic lupus erythematosis
SOB: shortness of breath sol: solution s/p: status post
STAT: immediately
STD: sexually transmitted disease
56
Subcut: subcutaneous
supp: suppository
susp: suspension
SVT: supraventricular tachycardia
sx: symptoms or signs
TAH: total abdominal hysterectomy
TB: tuberculosis
TCDB: turn, cough, deep breathe
THR: total hip replacement
TIA: transient ischemic attack
tid: three times a day
TKO: to keep open
TKR: total knee replacement
TPN: total parenteral nutrition
TPR: temperature, pulse, respirations
TSH: thyroid stimulating hormone
TURP: transurethral resection of the prostate
UA: urinalysis up
ad lib: up as desired or up as freely as desired
URI: upper respiratory infection
US: ultrasound
UTI: urinary tract infection
VS: vital signs
WBC: white blood count or white blood cell

Good luck & Study Hard!!!

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