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Chapter 14
Clinical observation
and Emergency Treatment for
critically ill patients
Emergency
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Section Ⅰ clinical observation
Section Ⅱ Emergency Treatment for
critically ill patients
Organization and management of resuscitation
Management of resuscitation equipments
Resuscitation skills commonly used
Supportive care for critically ill patients
Critically ill patients
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Critically ill patients are those who are in serious
condition, and may possibly have the danger of
life-threatening at any moment.
The basis to successful resuscitation is timely,
comprehensive and accurate observation and
recording of the patients’ condition.
 The key to successful resuscitation is to
apply all the resuscitation techniques
skillfully.
The guarantee to successful resuscitation is
the organization and management of rescuing
work.
Section Ⅰ clinical observation
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The purposes of clinical observation
The requirements of nursing staff
The methods of clinical observation
Contents of clinical observation
The purposes of clinical observation
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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
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rich and profound medical knowledge
great responsibility
acute observational ability
frequent
the principles of
being frequent in
five aspects.
inspection
frequent observation
frequent enquiry
frequent consideration
frequent
record
the methods of clinical observation
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inspection
auscultation
palpation
percussion
smelling
Besides the commonly used five methods above, health
care givers require effective communication.
Contents of clinical observation
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Observation of general condition
Observation of vital signs
Observation of consciousness
Observation of pupils
Observation of psychology
Observation of diagnostic studies or drug treatment
Observation of other aspects
Observation of general condition
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Development and body figure
Diet and nutritional status
Facial features and expression
Position
Posture and gait
Skin and mucous membrane
Observation of vital signs
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Body temperature
Pulse
Respiration
Blood pressure
Observation of consciousness
Consciousness is the comprehensive reflection
of how cerebrum reacts to the environment.
Disturbance of consciousness
Light coma
Somnolence
Confusion
Stupor
Coma
Deep coma
Glasgow Coma Scale, GCS
The scale comprises three tests:
 eyes opening (4 grades)
 verbal response (5 grades)
 and motor responses (6 grades)
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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.
Best eye response
There are 4 grades starting with the most severe:
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No eye opening.......................................1
Eye opening in response to pain...........2
Eye opening to speech ..........................3
Eye opening spontaneously.................4
Best verbal response
There are 5 grades starting with the most severe:
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No verbal response .................................1
Incomprehensible sounds ......................2
Inappropriate words ..............................3
Confused conversation ...........................4
Oriented ..................................................5
Best motor response
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There are 6 grades starting with the most severe:
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No motor response..................................1
Extension to pain ...................................2
Abnormal flexion to pain ......................3
Flexion/Withdrawal to pain ..................4
Localizing response to pain ...................5
Obeying command .................................6
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Observation of pupils
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The shape, size and symmetry of pupils
Light reaction
Shrinking:
the diameter of a pupil is smaller than 2mm.
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Bilateral pupil diminished may be seen when there
are poisoning conditions of organophosphorous
insecticides( 有 机磷 农药 ), chlorpromazine( 氯丙嗪 )
and morphine(吗啡).
Unilateral pupil diminished may indicate the
earlier stage of transtentorial hernia(小脑幕裂孔疝).
Largening:
the diameter of a pupil is bigger than 5mm, (mydriasis)
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Bilateral pupil dilated commonly is seen with the
state of intracranial hypertension( 颅 内 高 压 ),
craniocerebral injury ( 颅 脑 损 伤 ), Belladonna
poisoning (颠茄类药物中毒) and dying.
One side pupil dilated and fixed may indicate the
occurrence of transtentorial hernia (小脑幕裂孔疝)
which caused by same side intracranial hematoma
(颅内血肿) or brain tumor.
Observation of
diagnostic studies or drug treatment
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Observation after diagnostic studies or treatment
Observation of patients treated by special drugs:
the effect
the side effect
the toxicity of medications
Section Ⅱ
Emergency Treatment for critically ill patients
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Closely knit organization
Reasonable assignment
Essential and perfect equipment
Skilled medical workers
Necessary emergency drugs
Organization and management of resuscitation
Resuscitation team
director
head nurse
Formulate resuscitation plan
work out the nursing plan
cooperate with doctors
to carry on the rescue
record
verify
continue with the clinical observation after resuscitation
and pass nursing report to the next shift nurses.
attend while doctors conduct the ward round,
make consultations and discuss the cases of illness.
Management of resuscitation equipments
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resuscitation room
resuscitation bed
resuscitation cart
Emergency equipments
resuscitation cart
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Emergency drugs
Emengency sterile packages
others
Emergency equipments
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oxygen source
suction apparatus
electrical defibrillator
pacemakers
ECG (electrocardiograph) monitor
Ambu-bag
Respirator
Automatic gastrolavage machine, etc.
Management of equipments and drugs in
resuscitation room
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Strictly implement the “Five Fixed” system:
fixed amount
fixed places to arrange
fixed staff in charge
disinfecting at fixed time
maintenance at fixed periods
Resuscitation skills commonly used
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Cardio-pulmonary Resuscitation (CPR)
Gastric lavage
Sudden cardiac arrest，SCA
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CPR is a combination of oral resuscitation that
supplies oxygen to the lungs, and external cardiac
massage (chest compression), which is intended to
reestablish cardiac pump function and blood
circulation.
(Heart-lung resuscitation)
oral
resuscitation
chest
compression
when a cardiac arrest or respiratory arrest occurs,
a combined effort is made to restore or maintain
respiration and circulation, artificially.
The cardinal signs of a cardiac arrest
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unconsciousness
absence of a carotid pulse
apnea
dilated pupils
pale or cyanosed skin
absence of heart sounds
nil bleeding from wound
compression
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Basic Life Support (BLS) airway
breathing
Advanced life support(ALS)
Prolonged life support(PLS)
Purpose
To establish artificial circulation and respiration
To circulate oxygenation blood to the vital
organs to prevent permanent tissue damage
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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
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chest compression board
step bench
blood-pressure meter
Stethoscope
Oral airway or face mask if available
Ambu bag if available
Procedures-Assess whether victim is unconscious:
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shaking client's shoulders gently
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shouting
Procedures-If victim is not responsive,
activate Emergency medical
Services -EMS (call 120).
120
Procedures-
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Place the client on hard surface
Place the client in supine position
Take away pillow under client's head and loosen
client's collar and belt
Procedures-check the carotid pulse
Locate it by placing two
fingers in the groove between
the Adam’s apple and the
muscle.
★If there is a pulse
★If there is no pulse
＜10s
If there is a pulse
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ventilate victim at rate of one breath every 5
seconds (10-12/min)
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Recheck the carotid pulse every 2 minutes
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If breathing resumes, observe carefully to verify
continued spontaneous respiration.
If there is no pulse,
initiate chest compression
A person in bed must be moved to the floor,
or a cardiac board.
Locate the position for compression
Place the hands on the breastbone at the nipple line.
Place another hand on
top of the hand
the heel of the
hand
Keep fingers off
chest wall
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Extend arms and lock elbow.
Maintain arms straight and
shoulders directly over victim’s
sternum.
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Press straight down on the sternum,
compressing the chest 5 cm.
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Then release pressure, maintaining
contact with skin.
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Give compressions at rate of 100 /min,
counting “one and two and,” etc, up to 30.
Procedure-- open airway
head-tilt, chin-lift method
a.Place palm of one hand on
victim’s forehead.
b.Place fingers of another
hand under victim’s chin.
c.Simultaneously push down
on forehead and lift
upward on chin.
Use care to
avoid pressure
on the soft
tissue of the
throat.
jaw thrust method
—If head or neck trauma is suspected
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grasp angles of victim's
lower jaw and lift with
both hands, displacing
mandible forward.
If victim is not breathing,
administer artificial breathing
Mouth-to-mouth
Mouth-to-nose
Mouth-to-mouth/ nose
Mouth-to-mouth resuscitation
a. Pinch nostrils together.
b. take a deep breath and place mouth over the
victim’s mouth, forming a tight seal.
c. Blow two full breathes into the client's mouth (each
breath should last 1 second); allow the client to
exhale between breathes by loosing the nose.
Mouth-to-nose resuscitation
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Keep victim's head tilted with one hand on forehead.
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Use another hand to lift jaw and close mouth.
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Seal nurse's lips around victim's nose and blow.
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Allow passive exhalation.
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After 2 full ventilations,
reposition hands correctly,
give 30 compressions.
The ratio of compressions to breath is 30 to
2 for one or two rescuer.
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After the 5 cycle CPR, check carotid pulse and
resume CPR if absent.
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Recheck pulse every few minutes, but do not
interrupt CPR for more than 10s.
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Pulse should also be checked if signs of recovery such
as movement, swallowing, or returning facial color
occur.
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If pulse is present, continue ventilations every 5s
without compressions if the client does not resume
breathing.
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Continue CPR until heartbeat and breathing are
restored, EMS arrives, or victim is pronounced dead
by a physician.
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If heartbeat and breathing resume, continue to
observe and arrange for transport of victim to
hospital.
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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
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Acute toxicosis,
especially within 6h
after it
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.
Contraindications
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Clients who have ingested erosive (alkali or acid)
substance.
upper alimentary tract hemorrhage(上消化道出血);
upper alimentary tract ulcer;
gastric perforation(胃穿孔);
cancer of stomach;
Cirrhosis of liver(肝硬化) with esophageal and
gastric varication(食管胃底静脉曲张);
thoracic aortic aneurysm (胸主动脉瘤).
Common antidotes and contraindicated medications
Toxicant
Irrigating Solution
Contraindicated
Medications
Acid
substance
Alkaline
Milk of magnesia, egg-water, milk
Strong acid medication
5% acetic acid, egg-water, milk
Strong alkaline medication
substance
Cyanide
Induction of vomiting with 3% hydrogen peroxide
solution first, then irrigation with 1:15000-1:20000
Potassium Permanganate
Toxicant
Dichlorvos
1605
1059
4049
Dipterex
DDT
666
Phenols
saponated
cresol
Irrigating Solution
Contraindicated
Medications
Gastrolavage with 2%-4% baking soda,
l% saline, 1:15000-1:20000 Potassium Permanganate
Gastrolavage with 2%-4% baking soda
Potassium
Permanganate
Gastrolavage with 1% saline or water,
1:15000-1:20000 Potassium Permanganate
Alkaline
medication
Gastrolavage with warm water or. normal
saline, 50% magnesium sulfate catharsis
Oil cathartic
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
Toxicant
Irrigating Solution
Phenol
Gastrolavage with 1:15000-1:20000
Potassium Permanganate
Barbital
Gastrolavage with 1:15000-1:20000
Potassium Permanganate, catharsis
with Sodium sulfate
Isoniazid
Phosphatic
zinc
Contraindicated
Medications
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
Egg, milk, fat and
others
The preparation before operation
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Assessment
Assess the client and explain to him or her the
purpose and method of Gastrolavage and
precautions taken during operation.
Equipment
Tray
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Filler gastrolavage tube, forceps, and gauze
Toilet paper
Adhesive tape
Paraffin oil
Kidney tray
Sterile cotton swab
Plastic apron
Measuring cup
Thermometer
Tongue blade
Mouth-gag
Irrigating solution (25℃-38℃)
Buckets (one for filling gastrolavage irrigation, one for filling
waste water)
Test container or test tube
Equipment for gastrolavage with electric
suction apparatus
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Electric suction apparatus
Gastrolavage tube (without filler)
IV pole, bottle, and tube
Y-tube
Clamp
Equipment for lavage with automatic
gastrolavage machine
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Automatic gastrolavage machine
Gastrolavage tube (without filler)
Gastrolavage
-filler
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Oral emetic method
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Gastric tube method
irrigating gastrolavage
-electric suction apparatus gastrolavage
-automatic gastrolavage machine
Procedures ----Oral emetic method
--applied to clients with consciousness who
can cooperate with nurses.
 Ask the client to drink a lot of irrigating
solution, and induce vomiting.
400-500ml
fluid once
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Irrigating repeatedly until the returns from
stomach are clear and without smell.
Gastric tube-filler irrigating gastrolavage
inserting the filler gastric tube
Lower the filler below the level of stomach,
crush the rubber ball and aspirate
stomach contents
The tube is
inserted into
55-60cm
siphonage
1 Raise the filler
30～50cm over the
client's head
2 pour 300-500ml
irrigating solution
into the filler
3 When there are few
solutions in the filler,
lower the filler below the
level of stomach, and
inverses filler in the
bucket rapidly.
Repeat irrigating until the returns from stomach are clear
and without smell
Gastic tubeelectric suction apparatus gastrolavage
The negative
pressure is within
the range of about
13.3kPa.
transfusion
Bottle ( 300-500ml )
Gastic tubeelectric suction apparatus gastrolavage
transfusion tube
IV pole
Y-tube
gastrolavage
tube
irrigating
tube
Gastric tube-automatic gastrolavage machine
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.
waste
tube
irrigating
solution
The end of
gastric tube
Supportive care for critically ill patients
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Strengthen the monitoring of patients’ condition
Maintain a patent airway
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