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Chapter 14
Clinical observation
and Emergency Treatment for critically ill patients
Clinical observation is an important part of clinical nursing work. Timely and accurate
clinical observation is the basis of diagnosis, treatment and nursing of diseases.
Critically ill patients are those who are in serious condition, and may possibly have the
danger of life-threatening at any moment. These patients’ conditions change rapidly, so they need
the nursing staff to give strict and continual clinical observation, and can take the effective
measures promptly when the conditions change suddenly. Timely comprehensive and accurate
observation and recording of the patients’ conditions is the basis of rescuing them. Using each
kind of resuscitation techniques skillfully is the key to successful resuscitation, which may affect
the patients’ life and their quality of life directly. The organization and management of rescuing
work is the guarantee of rescuing critically ill patients.
SectionⅠ
clinical observation
Clinical observation is the process in which medical personnel use sense organs such as
vision, hearing, smell and touch to obtain the patients’ condition during clinical work, and to make
the synthetic judgement to the condition.
The purposes of clinical observation
·Providing the scientific basis to the diagnosis, treatment and nursing of diseases.
·Forecasting the trend and outcome of diseases.
·Knowing the effectiveness of treatment and medication effects on patients timely.
·Finding the signals of the changes of critically ill patients’ conditions, in case of the aggravation
of diseases.
The requirements of nursing staff
In order to observe and record the patients’ conditions exactly and timely, nurses are
supposed to be embodied with great responsibility, acute observational ability as well as rich and
profound medical knowledge and to implement the principles of being frequent in five aspects.
That is, frequent inspection, observation, enquiry, consideration and record. All these will prove to
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be feasible and effective in well grasping and predicting timely and accurately any changes in the
situation of patients so as to win time for duly resuscitation.
The methods of clinical observation
·Inspection
·Auscultation
·Palpation
·Percussion
·Smelling
Besides the commonly used five methods above, the information of patients’ condition may
also be obtained through communicating with doctors, patients’ family members, and reading
medical record, the survey report, the consultation report and other correlatively data, in order to
observe patients carefully and completely.
Contents of clinical observation
Observation of general condition
·Development and body figure
·Diet and nutritional status
·Facial features and expression
·Position active lying position, passive lying position, compelled lying position
·Posture and gait waddling gait; drinking man gait; ataxic gait; festinating gait; scissors gait;
intermittent claudication; protective claudication
·Skin and mucous membrane
mainly observe its color, temperature, humidity, flexibility, and
whether there is bleeding, dropsy, skin rash, hypodermic tubercle and cyst.
Observation of vital signs
·Body temperature
·Pulse
·Respiration
·Blood pressure
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Observation of consciousness
Consciousness is the comprehensive reflection of how cerebrum reacts to the environment.
The normal person should have the clear consciousness, fluent and accurate language, reasonable
thought, exact judgment and orientation to the time and place. Disturbance of consciousness is a
state of mind that the individuals lack the normal response to the external environment stimulation.
Whatever reasons result to the damage of the cerebral cortex function, the disturbance of
consciousness may happen. It may be generally divided into:
·Somnolence It’s the lightest disturbance of consciousness. The patients are in a state of
continual sleep, but they can be awakened by speaking to them or mild stimulation. After awaking,
they can answer questions correctly, simply and slowly, but the response is very slow. They may
fall asleep again after the elimination of stimulation.
·Confusion Patients may have incoherent thought and language, and the barrier to orientation to
the time, place and person completely or partly. They may also have the illusion, restless moving,
raving or dementia.
·Stupor Patients are in sound sleep, not easy to wake up. The strong stimulation may awaken
them. But they reply ambiguously or irrelevantly after awaking, and fall in sound sleep again after
stopping the stimulation.
·Coma
It’s the most serious of disturbance of consciousness. ①Light coma: The majority of
consciousness has been lost. Patients have no independent movement. There are no response to the
sound and the light stimulation. They may have the painful expression and the withdrawal to pain
to the ache stimulation. The pupil’s light reaction, the corneal reflex, the eye movement, the
swallowing reflex and the cough reflex nay exist. The breath and blood pressure change
unobviously. There may be the feces and urine incontinence or retention. ②Deep coma:
Consciousness loses completely. No response to any kind of impetusing. The whole body muscle
is relaxed. The deep reflex vanishes. Organism can only maintain the most basic function of
circulation and breathing. The breath is anomalous, and the blood pressure may drop. There are
the feces and urine incontinence or retention.
In hospital medical workers may also use Glasgow Coma Scale to assess the consciousness
of a patient. The scale was published in 1974 by Graham Teasdale and Bryan J. Jennett, professors
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of neurosurgery at the University of Glasgow. It is a neurological scale which aims to give a
reliable, objective way of recording the conscious state of a person. GCS was initially used to
assess level of consciousness after head injury, and the scale is now used by first aid and EMS
(Emergency Medical Service). In hospital it is also used by medical and nursing staff for initial as
well as continuing assessment in chronic patient monitoring, in for instance, intensive care. The
scale comprises three tests: eyes opening (4 grades), verbal response (5 grades), and motor
responses (6 grades). The three values separately as well as their sum are considered. A patient is
assessed against the criteria of the scale. The highest possible GCS (the sum) is 15 (fully awake
person), while the lowest is 3 (deep coma or death). If the score is less than 7 and more than 3, it’s
light coma.
Table 14-1 The Glasgow Coma Scale (GCS)
Test
Best
Eye Opening
Best Verbal
Response
Best Motor
Response
State
Score
Eyes opening Spontaneously
Eye opening to speech
Eye opening in response to pain
(Pain from sternum/limb/supra-orbital pressure)
No eye opening(Even to supra-orbital pressure)
4
3
2
Oriented: (Patient knows who he is, where he is and why, the year,
season, month etc.)
Confused conversation: (The patient responds to questions coherently
but there is some disorientation and confusion.)
Inappropriate words. (Random or exclamatory articulated speech, but
no conversational exchange)
Incomprehensible sounds. (Moaning but no words.)
No verbal response
5
Obeying command: (The patient does simple things you ask )
Localizing response to pain: (Purposeful movements towards painful
stimuli; e.g., hand crosses mid-line and gets above clavicle when
supra-orbital pressure applied.)
Flexion/Withdrawal to pain: Pulls limb away from painful stimulus.
Abnormal flexion to pain: Pressure on the nail bed causes abnormal
flexion of limbs – “decorticate posture”.
Extension to pain: (adduction of arm, internal rotation of shoulder,
pronation of forearm, extension of wrist, decerebrate response)
No motor response (No response to pain)
6
5
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1
4
3
2
1
4
3
2
1
Observation of pupils
When the patient suffers the encephalic disease, and is in conditions of drug poisoning and
stupor, pupil's changes are an important indication of the changes of the condition. When the
medical workers observe the pupil, they should pay more attention to the shape, the size, the
symmetry, the edge and to the light response of both sides pupils.
·The shape, size and symmetry of pupils
Normally, pupils are round and in the middle of eyes. The edges of them are tidy. It’s the
same size and circle on both sides. Under the natural light, pupil's diameter is generally 2~5mm.
In the pathology situation, pupil's size may have some changes: ① Shrinking: Shrinking means
that the diameter of a pupil is smaller than 2mm. If the pupil’s diameter is smaller than 1mm, it
can be called the pinpoint pupil. Unilateral pupil diminished may indicate the earlier stage of
transtentorial hernia. Lateral pupil diminished may be seen when there are poisoning conditions of
organophosphorous insecticides, chlorpromazine and morphine. ② Largening: When the pupil’s
diameter is bigger than 5mm, it can be called the mydriasis. One side pupil dilated and fixed may
indicate the occurrence of transtentorial hernia which caused by same side intracranial hematoma
or brain tumor. Bilateral pupil dilated commonly is seen with the state of intracranial hypertension,
craniocerebral injury, Belladonna poisoning and dying.
·Light reaction
In normal condition, pupil gets smaller in luminous place, and bigger in dark hidden place. If
the size of pupil does not change along with photic stimulation, it means the vanishing of pupil’s
light reaction, which is generally seen in seriously injured or the deep stupor patients.
Observation the state of psychology
Observation of diagnostic studies or drug treatment
·Observation after diagnostic studies or treatment Nurses should grasp the notes to nursing
around the check-up, observe the vital signs closely, and listen attentively to the patient’s
complaints in order to prevent the complication.
·Observation of patients treated by special drugs Nurse should observe the effects, the side
effects and the toxicity of medications.
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Observation of other aspects
Section Ⅱ Resuscitation and care for critically ill patients
It is a urgent task for medical and nursing staff to rescue critically ill patients. Rescue
requires closely knit organization, reasonable assignment, essential and perfect equipment, as well
as skilled medical workers and necessary first-aid medicine, which will make sure the rescue is
carried out timely, accurately and effectively.
Organization and management of resuscitation
·Resuscitation team should be made up immediately. Generally the director and head nurse is
responsible to organize the rescue in ward. All medical workers must obey the direction.
·Resuscitation plan should be formulated. The nursing staffs should work out the nursing plan
according to patient's situation and the rescue plan. They must identify nursing diagnosis, establish
expected outcomes, and design nursing interventions.
·Nurses should cooperate with doctors to carry on the rescue, complete the record and the
verification of the rescue. Rescue record should be Timely, Accurate, Complete, neat and legible,
and the time of executing and performer should be noted. When the physician gives oral orders,
nurses who are assisting him or her have to repeat the order once again and make sure it is correct.
After the emergency the physician should record and sign all orders and prescriptions that were
given. All empty ampoules, solution container, the blood bag and so on in the rescue should be
reserved in order to check.
·Nurses should continue with the clinical observation after rescue and pass nursing report to the
next shift nurses.
·Nurses should attend while doctors conduct the ward round, make consultations and discuss the
cases of illness. They should be familiar with conditions, the key monitoring items and the rescue
process of critically ill patients, in order to achieve appropriate cooperation.
Management of resuscitation equipments
Resuscitation room
Resuscitation bed
Resuscitation cart
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·Emergency drugs: Include central nervous stimulant; pressure-rising drugs/hypertension drugs;
cardiotonic; diuretic; hemostatic; antidote (detoxicants); analgesia and sedative, etc.
·Emengency sterile packages: Include venetomy packeage; endotracheal intubation package;
tracheostomy package; puncture package, etc.
·Others: Include Sphygmomanometer; Stethoscope; gag; tongue blade; tongue forceps; forceps;
flash light; tourniquet; Syringes; Antiseptic solution; Sterile swab; Tape; alcohol burner; Sterile
glove; power plug, etc.
Emergency equipments: Include oxygen source; suction apparatus; portable or wall suction
apparatus; electrical defibrillator; pacemakers; ECG monitor; Ambu-bag; Respirator; Automatic
gastrolavage machine, etc.
Management of equipments and drugs in resuscitation room
All the equipments mustn’t be lent out. And they must be cleaned timely after being used,
returned to the original place and supplemented in case of the next rescue. Guarantee the
soundness of all emergency equipments.
Strictly implement the “Five Fixed” system, that is, fixed amount, fixed places to arrange, fixed
staff in charge, disinfecting at fixed time, and maintenance at fixed periods.
Resuscitation skills commonly used
Cardio-pulmonary Resuscitation
If a client's hypoxia is severe and prolonged, cardiac arrest may result. A cardiac arrest is the
cessation of cardiac function. When it occurs, the heart no longer pumps blood to any organ of the
body. Breathing then stops, and the person becomes unconscious and limp. Within 20 to 40
seconds of a cardiac arrest the person is clinically dead. After 4 to 6 minutes the lack of oxygen
supply to the brain causes permanent and extensive damage. The three cardinal signs of a cardiac
arrest are apnea, absence of a carotid or femoral pulse, and dilated pupils. The person's skin
appears pale or grayish and feels cool. Cyanosis is evident when respiratory function fails prior to
heart failure. A respiratory arrest is the cessation of breathing. It often occurs after a blocked
airway, or following a cardiac arrest and for other reasons. It may occur abruptly or be preceded
by short, shallow breathing that becomes increasingly labored.
Cardio-pulmonary Resuscitation (CPR) is a combination of oral resuscitation that supplies
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oxygen to the lungs, and external cardiac massage (chest compression), which is intended to
reestablish cardiac pump function and blood circulation. It is also called as basic life support,
which consists of ABC process: A-airway, B-breathing, and C-circulation. All nurses should be
trained to perform CPR procedures so that resuscitation measures can be initiated immediately
when a cardiac arrest or respiratory arrest occurs.
The cardinal signs of a cardiac arrest
·Unconsciousness
·Absence of a carotid pulse
·Apnea
·Dilated pupils
·Pale or cyanosed skin
·Absence of heart sounds
·Nil bleeding from wound
Skill 14-1 Cardio-pulmonary Resuscitation
Purposes
·To establish artificial respiration and circulation
·To circulate oxygenation blood to the brain to prevent permanent tissue damage
Indications
Cardiac arrest and/or respiratory arrest
Contraindications
·Presence of heart beat and breathing
·Severe injuries to thorax or heart
·Severe deformity of thorax and spine
Equipment
·Ambu-bag if available
·CPR pocket mask or barrier if available
·Chest compression board and step bench if available
·Resuscitation cart if available
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·Sphygmomanometer and stethoscope
·Face shield and gloves if available
Procedures and Key Points
Steps
Rationale and Key Point
1. Determine if the client is unconscious by
shaking client's shoulders and shouting near
the client's ears
2. Activate emergency medical services or call
other people for help
3. Assess the breath and carotid or brachial
(use with infants) pulse
4. Place victim on hard surface such as
backboard, ground, or floor. Put the client
to be flat. Take away pillow under client's
head and loosen client's collar and belt
·To confirm that the client is unconscious as
opposed to intoxicated, sleeping, or hearing
impaired
5. Assume correct and comfortable position
for the rescuer
6. If available, apply gloves and face shield
7. Open airway:
(1) Use head-tilt/ chin-lift method: The rescuer
tilts the client's head back with one hand
while lifts up client's chin with another
hand
(2) Use head-tilt/neck-lift method: The rescuer
raises client's neck with one hand and tilts
the client's head back with another hand
(3) Jaw thrust method: The rescuer grasps
angles of victim's lower jaw and lift with
both hands, displacing mandible forward
while titling head backward
8. If readily available, insert oral airway
9. If the client does not resume breathing,
administer artificial breathing.
(1) Mouth to mouth: Pinch the client's nose
· Presence of pulse and respiration
contraindicates initiation of CPR
·In the procedure of chest compression, the
heart is compressed between sternum and spinal
vertebrae, which must be on a hard and firm
surface. Place chest compression board under
client's shoulder and back for those who lie on
the soft mattress
·Correct position avoids fatigue and promotes
more effective compressions
·To reduce transmission of microorganisms
·The tongue is the most common cause of
airway obstruction in an unconscious client.
Airway obstruction from the tongue is relieved
through opening airway. If necessary, remove
foreign body from the mouth
·It is applicable for client with no neck trauma
·When head and / or neck trauma is suspected,
this maneuver opens the airway while
maintaining proper head and neck alignment,
thus reducing the risk further damage to the
neck
·Maintains tongue on anterior floor of mouth
and prevents obstruction of posterior airway by
tongue
·Airtight seal is formed, and air is prevented
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with thumb and index finger, and occlude
mouth with rescuer's mouth or use CPR mask.
Blow two slow, full breaths into the client's
mouth (each breath should last 1 seconds);
allow the client to exhale between breaths by
loosing the nose
from escaping through nose
·Hyperventilation is promoted and assists in
maintaining adequate blood oxygen levels. In
most adults this volume is 700 to 1000ml and is
sufficient to make the chest rise
·Maintain head tilt-chin lift while administering
breaths which allows air enters the lungs
·Blowing rate for adults is 10-12 per minute,
12-20/min for children and infants
· Chest movement can be observed when
blowing is performed effectively
(2) Mouth-to-nose: Keep victim's head titled
with one hand on forehead. Use other hand to
lift jaw and close mouth. Seal nurse's lips
around victim's nose and blow. Allow passive
exhalation
·For the clients whose mouths can not be
opened or jaws or mouths are seriously injured,
mouth-to-nose ventilation can be more effective
·Blowing with more time and effort overcomes
resistance from nose
(3) Mouth-to-mouth/ nose: Seal nurse's lips
around both victim's nose and mouth and blow
(4) Ambu-bag: Use proper-size face mask and
apply it under chin, up and over victim's
mouth and nose for both adult and child
victim
10. Observe for rise and fall of chest wall with
each respiratory. Listen for air escaping during
exhalation, and feel for flow of air. If lungs do
not inflate, reposition head and neck and
check for visible airway obstruction, such as
vomitus
·It is applicable for infants and young children
·Blowing with less time and effort
· If it is feasible, endotracheal tracheal
intubation is performed for effective artificial
breathing and maintaining patent of airway
11. After two breathes, check for presence of
carotid (adults) or brachial (infants) pulse
· Carotid artery pulse is the most easily
accessible and persists when other peripheral
pulse are no longer palpable
12. If pulse is absent, initiate chest
compressions:
(1) Adult: Using two fingers of one hand
marks the xiphoid process and then placing
the heel of the other hand next to them. The
hand marking the xiphoid process can then be
moved and placed on top of the other hand.
Keeps hands parallel to chest and fingers
above chest. Interlocking fingers is helpful.
Keep fingers off chest wall. Extend arms and
· Correct place of chest compression is
junctional place between middle and lower 1/3
of sternum. Correct placement of hands and
fingers over sternum prevents rib fracture,
damage to abdominal organs, reflux of gastric
content, and other complications
·Compression occurs only on sternum and is
meant to squeeze the heart between the sternum
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lock elbow. Maintain arms straight and
shoulders directly over victim’s sternum and
compress sternum to proper depth from
shoulders and then release pressure,
maintaining contact with skin to ensure
ongoing proper placement of hands. Do not
rock, but transmit weight vertically down
(2) Child: Place the hands on the breastbone
at the nipple line. Maintain head titlet with
other hand, if possible, to maintain patent
airway
(3) Infant: Place index and middle fingers of
one hand above xiphoid process. Fingers
should be 1cm below nipple line and
perpendicular to sternum and not slanted
13. Palpate for carotid or brachial pulse with
each external chest compression for first full
minute (the other rescuer does it). If the
carotid pulse is not palpable, compressions are
not strong enough or hand position is incorrect
14. Assess carotid pulse at 5-minute intervals
following first minute of CPR
15. If the client restores automatic breath and
heat beat, refer him or her to the hospital for
advanced life support
16. Records in nurse's notes and appropriate
code sheet about onset of arrest, medication
and other treatments given, procedures
performed, and victim's responses
and spin. Pressure necessary for externa1
compression is created by the rescuer's upper
arm muscle strength and upper body. When
compression is released, the heart fills
The ratio of compressions to breath is 30 to 2
(for one or two rescuer )
·Time ratio of compression and relaxation is
1:2
·Proper depth of compression:
Adult and adolescent: 4 to 5cm
Older child: 3 to 4cm
Toddler and preschooler: 2 to 4cm
Infant: 1 to 2cm
·To maintain proper rate of compression:
Adult and adolescent: 100/min
Child: 100/ min
Infant: at least 100/min
·The ratio of compressions to breath for one
rescuer is 30 to 2, for two rescuer, the ratio is 15
to 2
·The index of effect external chest compression
includes presence of big artery pulse, systolic
blood pressure above 60mmHg, and skin and
lip's color turning to red
· Artificial cardiopulmonary function is
maintained
· To continue CPR until victim regains
spontaneous pulse and respirations, or physician
discontinues CPR
· To document the adequacy of artificial
circulation and adequacy of artificial
cardiopulmonary function
·CPR is not interrupted for more than 5 seconds
·CPR includes basic life support, advanced life
support, and prolonged life support
·To ensure the continuity of emergency care
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Skill 14-2 Gastric lavage
Gastric lavage is a medical approach for therapeutic irrigation of stomach by inserting a
gastrolavage tube to stomach via mouth or nasal cavity, through which certain quantity of
irrigating solution is pumped into stomach by gravity, siphonage, and negative pressure suction.
Purpose
·Detoxification: Clear the stomach contents or other harmful substance.
·Alleviate the edema of stomach mucosa: Wash out food in stomach; Alleviate stimulation, edema
and inflammation of stomach mucosa.
·preparations needed before some operation or diagnostic studies
Indication
·Acute toxicosis, especially within 6h after it
·Before some operation or check
Contraindications
·Clients who have ingested erosive (alkali or acid) substance.
·Convulsion patients, because the tube insertion may increase severity and frequency of seizures.
·Cirrhosis of liver with esophageal and gastric varication; thoracic aortic aneurysm; upper
alimentary tract hemorrhage; upper alimentary tract ulcer; gastric perforation; cancer of stomach,
etc.
Common antidotes and contraindicated medications(Table 14-2)
Table 14-2 Common antidotes and contraindicated medications
Toxicant
Irrigating Solution
Acid substance
Alkaline substance
Cyanide
Milk of magnesia, egg-water, milk
5% acetic acid, egg-water, milk
Induction of vomiting with 3% hydrogen
peroxide solution first, then irrigation with
1:15000-1:20000 Potassium Permanganate
Gastrolavage with 2%-4% baking soda,
l% saline, 1:15000-1:20000 Potassium
Permanganate
Gastrolavage with 2%-4% baking soda
Strong acid medication
Strong alkaline medication
Gastrolavage with 1% saline or water,
1:15000-1:20000 Potassium Permanganate
Alkaline medication
Dichlorvos
1605
1059
4049
Dipterex
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Contraindicated Medications
Potassium Permanganate
DDT 666
Phenols saponated
cresol
Phenol
Barbital
Isoniazid
Phosphatic zinc
Gastrolavage with warm water or. normal
saline, 50% magnesium sulfate catharsis
Gastrolavage with warm water and
vegetable oil until no phenols smell, then
ask the client to drink milk, or egg white to
protect stomach mucosa
Gastrolavage with 1:15000-1:20000
Potassium Permanganate
Gastrolavage with 1:15000-1:20000
Potassium Permanganate, catharsis with
Sodium sulfate
Gastrolavage with 1:15000-1:20000
Potassium Permanganate, catharsis with
Sodium sulfate
Gastrolavage with 1:15000-1:20000
Potassium Permanganate, or 0.1% copper
sulphate
Oil cathartic
Egg, milk, fat and others
The preparation before operation
· Assessment
assess the client and explain to him or her the purpose and method of
Gastrolavage and precautions taken during operation.
·Equipments
Tray
·Filler gastrolavage tube, forceps, and gauze (packed with sterile towel)
·Toilet paper
·Adhesive tape
·Paraffin oil
·Kidney tray
·Sterile cotton swab
·Plastic apron
·Measuring cup
· Thermometer
·Tongue blade
·Mouth-gag
·Irrigating solution (25°C-38°C)
·Buckets (one for filling gastrolavage irrigation, one for filling waste water)
·Test container or test tube
Equipment for gastrolavage with electric suction apparatus
·Electric suction apparatus
·Gastrolavage tube (without filler)
·IV pole, bottle, and tube
·Y-tube
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·Clamp
Equipment for lavage with automatic gastrolavage machine
·Automatic gastrolavage machine
·Gastrolavage tube (without filler)
Procedures and Key Points
Steps
Rationale and Key Point
1.Wash hands, and wear mask, and prepare the
irrigating solution
·When nurses don't know the poison, choose
warm water or normal saline. After nurses know
the poison, choose relevant antagonist
2.Prepare the equipment and take them to the
client
3.Check the client's bed number and name
according to the physician's order
·Gastrolavage requires a physician's order
4.Explain the purpose and procedure to the
client, instruct the client how to cooperate
·Reduce the client's anxiety and make him
understand the procedure
5.Assist the client to a suitable position. Place
a rubber apron across the client's chest, place
a tray under the mandible, and buckets in
front of seat or under the head of bed
·Oral emetic method: clients can have a sitting
position
·Gastric tube gastrolavage: clients who are mild
intoxication can have a sitting
position or
Fowler's position; clients who are severe
intoxication can have left side-lying position
·Coma: clients should have a supine position,
and the pillow is removed, and the client's head
is turned to one side
6.Gastrolavage
Oral emetic method
(1) Ask the client to drink a lot of irrigating
solution, and induce vomiting. Nurses can
also use tongue blade to· press client's
lingual root to induce vomiting if necessary
(2) Irrigating repeatedly until the returns from
stomach are clear and without smell
Gastric tube-filler irrigating gastrolavage
(1) The procedure of inserting the filler gastric
tube is similar to the procedure of inserting
the nasogastric tube. The tube is inserted into
55-60cm, and is confirmed in stomach. The
adhesive tape is used to fix the tube
· This procedure is applied to clients with
consciousness who can cooperate with nurses
·The client drinks 400-500ml fluid once
·This shows that the poison is eliminated
· The act of inserting tube should be gentle and
safe
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(2) Lower the filler below the level of
stomach, crush the rubber ball and aspirate
stomach contents
(3) Raise the filler 30-50cm over the client's
head and pour 300-500ml irrigating solution
into the filler. When there are few solutions
in the filler, lower the filler below the level
of stomach and inverses filler in the bucket
rapidly
(4) Repeat irrigating until the returns from
stomach are clear and without smell
Gastic tube-electric
gastrolavage
suction
apparatus
(1) Electrify suction apparatus and check its
function
(2)Connect transfusion tube with main tube of
Y-tube. Join gastrolavage tube and irrigating
tube to two branches of Y-tube respectively.
Pour the irrigating solution to the transfusion
bottle, clamp the transfusion tube, and hang
it on the IV pole
(3)Insert the gastrolavage tube, and confirm
the tube in the stomach
(4)Start operating the electric suction
apparatus and aspirate the contents of
stomach
·Crushing the rubber ball can produce negative
pressure. Gastric contents need to be sent for
test
·The temperature of irrigating solution is 25℃
-38℃. Extreme high temperature makes
vasodilatation and accelerates the absorption of
poison. Extreme low temperature can cause
gastrospasm
·The total amount of irrigating solution is
300-500ml each time. Too much solution can
cause gastric retention, accelerate the contents
into intestine and increase absorption of the
poison. A small amount of irrigating solution
cannot irrigate the stomach entirely
·The total quantity of irrigating should be equal
to the total quantity of aspirating. This can
prevent gastric retention
·Using the negative pressure to aspirate the
stomach contents and the poison
·Ensure the effect of negative pressure suction
·The negative pressure is within the range of
about 13.3kPa. This can avoid damage to
stomach mucosa. When we do not know what
kind of the poison is, we can take sample to test
(5)Clamp the drainage tube, open the
transfusion tube and instill 300-500ml
irrigating solution to the stomach
(6)Clamp the transfusion tube, open the
drainage tube, operate electric suction
apparatus, and aspirate the irrigating solution
(7)Repeat irrigating until fluid return is clear
and without smell
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Gastric
tube-automatic
gastrolavage
machine
(1)Check the function of automatic
gastrolavage machine
(2)Insert the gastrolavage tube, and confirm
the tube in the stomach
(3) Pour the irrigating solution into the bucket,
and connect three rubber tubes respectively
to the medication tube, gastric tube and
waste tube. Put the other end of medication
tube in the irrigating solution bucket, and put
the other end of waste tube in the empty
bucket. Attach the other end of gastric tube to
client's gastric tube. Adjust the rate of
medicine flow
(4) Press the manual flush button, and the
suction machine begins to aspirate the
stomach contents. Then press the
“automatic” flush button, and the machine
begins to flush stomach automatically
(5) If tube is obstructed, slow water flow. If no
water flow and other problems occur, we can
press manual flush button and manual
suction button for flush and suction
alternately. Repeat flushing and suction
several times until the tube becomes clear.
Then press manual button for suction and
aspirate the stomach contents. Press
automatic button, and the automatic
gastrolavage machine will operate
(6) After the aspirated fluid is clear, nurses can
press stop button, and the automatic
gastrolavage machine will stop working
7.Observe the client's face color, pulse,
respiration and blood pressure; the color,
smell, amount of aspirated fluid; and whether
there are complications or not
8. Withdraw the gastric tube. Assist the client
with oral hygiene and face washing. Remove
the equipment
9. Document relevant information
·The end of medication tube is immerged in
irrigating solution all the time
·When the machine begins to flush, the manual
flush button lights; When the machine begins to
aspirate, the manual suction button lights
·After the tube is clear, nurses should aspirate
the stomach contents in advance and then press
automatic button. Otherwise excessive irrigating
solution can cause gastric retention
· Complications of gastrolavage: gastric
perforation, water intoxication, fluid and
electrolyte imbalance, acute gastrectasia,
cardiac arrest
·If abdominal pain, shock occur, nurses should
stop gastrolavage at once and take some
emergency measures
·Oral hygiene keeps mouth clean and moist,
and promotes comfort
· Record name, amount of the irrigating
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solution; the type, smell, amount of the
aspirated fluid; and the client's response
Evaluation
·Toxicant is effective eliminated.
·Clients' suffering and symptoms are alleviated.
·Correct procedure and no complications.
·Clients can understand the procedure and cooperate with nurses.
Supportive care for critically ill patients
Regarding the nursing of critical patients, nurses can utilize each kind of rescue technology
skillfully, and must strengthen various nursing of patients, such as foundation nursing, in order to
reduce the pain of patients, and prevent the complication.
Strengthen the monitoring of patients’ condition
Nurses should monitor various system functions of critically ill patients continually, such as
the central nervous system, circulatory system, respiratory system, urinary system, and so on.
Maintain a patent airway
Airway maintenance requires proper coughing techniques to remove secretions and keep
airway open; and a variety of interventions to assist the patient with alteration in airway clearance,
including suctioning, chest physiotherapy, and nebulizer therapy.
strengthen the clinical basic care
·Maintain good hygiene of a patient
·Eyes care
·Oral care
·Skin care
·Keep excretory system functions
·Maintain the function of limbs
·Pay attention to patients’ safety
·Keep the drainage tube unobstructed.
emphasize psychological care for critically ill patients.
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