NCLEX RN presentation

1. Critical Care Nursing
NCLEX NOTES-FOR QUICK REVISION

2. Learning Objective
By the end of this presentation, candidates will be able to
understand;
 Method of Prioritizing Assessments
 Critical Incident Management
Managing aggressive and violent patients
Legal and Ethical issues (frequently occur in Emergency care)
 Managing Cardiovascular emergencies, respiratory emergencies,
neurological emergencies.

3. Prioritization of Assessments

4. Using ABCDE-Initial Assessment Criteria
Airway • Visual airway threats
• Voice clarity
• Audible breath sounds (without
stethoscope)
Breathing • Respiratory rate (12-20)
• Work of breathing
• Pulse Ox
Circulation • Color
• Bleeding
• HR & BP
Disability • Level of Consciousness (neuro status)-
AVPU
• Orientation
Exposure • Temp (blankets)
• Clothing (gown)

5. Analyze results of initial assessment
A. Abnormal: Initiate life saving treatment, Notify provider
B. Normal: Proceed to focused assessment
Information about chief complaint
◦ Started when?
◦ Doing what?
◦ Happened before?
◦ Better/worse? Any other/associated symptoms
 Up to date medical history
Up to date medication list
System Assessment(s)

6. Tips to remember
A.Higher Acuity Patients
◦More detailed assessments
◦AFTER ALL life saving interventions completed
B. Pt with Multiple Complaints
◦Assessment of every system affected
C. LISTEN to their answers!
◦Add appropriate assessments!

7. Reassessment
A.Remember to constantly reassess
I. Add Vital Signs
II.Before & after interventions
III.Prior to conclusion of care
◦ Before discharge
◦ Before admission to floor
B.Facility Requirements

8. Example of Assessment-Ankle Pain
Chief complaint: Ankle pain
Questions to ask;
 Started when? ‘After I fell’
Doing what? “I tripped”
How (abuse?)? “I got dizzy”-Syncope-Additonal cardiac, resp, & neuro assessment
Happened before? No, if Yes-Social work? Home safety?
Better or worse?
Associated other symptoms? Other injuries
Medical History
Medication list
System Assessment: deformity, pedal pulse, color, sensation, range of motion

9. Example of Assessment-Abdominal pain
Chief complaint: Abdominal pain
Questions to ask;
 Started when? ‘last night’
Doing what? “Watching TV”
Happened before? Yes-Seen by MD then?
Better or worse? ‘After I eat’
Associated other symptoms? Nausea
Medical History
Medication list
System Assessment: abdominal inspection,auscultation, palpation, last bowel
movements, urinary compliants, LMP, Sexual history

10. Example of Assessment-Chest pain
Chief complaint: Chest pain
Questions to ask;
 Started when? ‘Three Hours Ago’
Doing what? “Walking to mailbox”
Happened before? Yes-When? ‘My last heart attack’
Better or worse? ‘After walking’
Associated other symptoms? SOB ((repeat chief complaint questions), Nausea: Add GI
assessment
Medical History: Details for last MI + Last cardiology visit
Medication list
System Assessment: chest inspection,auscultation of breath sounds and heart sounds, assess
perfusion, capillary refill, pulses, edema

11. Triage

12. Overview
Triage is the process of sorting patients as they
come into the ED in order to determine who needs
immediate attention and who can wait. It requires
expert clinical judgement by an experienced nurse.
The current recommendation from ACEP and the ENA
is the use of a 5-level triage system. The Emergency
Severity Index is the standard of care in the United
States and is based on severity of symptoms and
resource utilization.

13. Triage Assessment
I. Walking through the door
A.Across the room assessment
◦ Look
◦ Listen
◦ Smell
B.Triage Interview
C.Triage Vitals
D.Objective assessments

14. Triage Assessment
I. Walking through the door
A.Across the room assessment
◦ Look
◦ Listen
◦ Smell
B.Triage Interview
C.Triage Vitals
D.Objective assessments

15. Triage Assessment
I. Walking through the door
A.Across the room assessment
◦ Look
◦ Listen
◦ Smell
B.Triage Interview
C.Triage Vitals
D.Objective assessments

16. Triage Assessment
II. Triage Severity Rating
A. Emergency Severity Index (ESI)
B. 5-Levels
1 – Immediate (Intubated, apneic, pulseless)
2 – Not as immediate (But still in pretty bad shape)
3 – You can wait, but you may need some stuff
 Two of more resources or vitals in the “danger zone”
4 – You can also wait because you are going to need one specific thing
 Only needs one resource (An x-ray, an oral antibiotic, etc.)
5 – Please have a seat (Or head to the urgent care center down the block)
 No resources needed

17. Triage Severity Rating (cont..)
C. Resources:
Labs (blood, urine)
ECG, x-rays, CT, MRI,
Ultrasound
IV fluids
IV, IM or nebulized meds
Speciality consultation
Simple procedure =1 (Lac
repair, Foley)
Complex procedure =2
(conscious sedation)
D. Not Resources:
History and Physical
assessment
Point of care testing (Finger
stick, Urine Pregnancy test)
Heplock
PO meds, script refills
Phone call by PCP
Simple procedure =1 (Lac
repair, Foley)
Simple wound care (dressing,
wound check)
Crutches, splint, sling

18. Triage Assessment
III. START Triage: Simple Triage And Rapid Treatment
When things get sideways
Greatest good for the greatest number
Dreaded black tag
Patient Education
Allow the professionals to act
Ask before assisting (if you can)

19. Critical Incident Management

20. What is considered a “Critical Incident”?
A. Any unplanned or imminent event that affects or
threatens the health, safety, or welfare of people,
property and infrastructure.
B. Requires a significant and coordinated response.
C. Typically overwhelms resources or has the potential
to.

21. Types of Critical Incidents
1. Fire / Flood
2. Unplanned evacuation
3. Bomb threat
4. Active shooter
5. Earthquake / Hurricane / Tornado
6. ED overcrowding
7. Mass casualty
8. Violence

22. How do we prepare?
A. Training
I. Didactic
II. Simulation
III. Drills / Full scale exercise
IV. Trial and error?
B. Develop protocols
I. Disaster plan
II. Emergency Management plan (EOM involvement)

23. Nurses role in a critical incident
A. Know the chain of command
B. Do not forget the basics
I. Protect yourself
II. Protect your patient
A. Start Triage
B. Collaboration
I. Within the department
II. Within the agency
III. Within the community

24. What do to after the threat passes?
A. Critical Incident Stress Debriefing
I. 7-Phase process
II. 24-72 hours after completion of acute incident phase
III. Small groups – directly involved in incident

25. Aggressive & Violent Patients

26. What is an aggressive or violent patient?
A. Profane or disrespectful language
B. Sexual comments
C. Inappropriate touching
D. Racial jokes
E. Outbursts of anger / throwing things
F. Retaliation
G. Aggressive physical contact or restraint: Medical vs
behavioral vs situational

27. Obstacles to addressing these patients
A. “Just part of the job”
B. Lack of communication skills
C. Fear of reprisal (no one will back us up)
D. Lack of resource

28. Prevention First
A. Initial contact
B. Use the patients name
C. Give generous time estimates (If you know it takes 10
minutes…tell them 20, don't undersell)
D. Don't cross your arms
E. Establish availability
F. Sit near the patient
G. Don't write or type while patient describing main concern
H. Therapeutic touch: DON’T FORGET YOUR PATIENTS

29. Dealing with the situation
Techniques Description
De-escalation • Move to a private area.
• Be empathetic and non-judgmental
• Respect personal space
• Keep your tone and body language neutral
• Avoid over-reacting
• Focus on the thoughts behind the feelings
• Set boundaries
Challenging the nurse / doctor • Let the patient vent
• Be empathetic
• Repeat information and speak to patients
feelings
• Watch your body language
Non compliance • Set limits
• Provide time frame for choices
• Establish consequences

30. Dealing with the situation (Cont..)
Techniques Description
Emotional release • Let the person vent privately (remove the
audience)
• Undivided attention
• Listen to what is not being said
• Don't turn your back
Challenging the nurse / doctor • Maintain space (at least 2-3 feet away)
• Open stance
• Open hands (not in your pockets)
• Remove anything that could be a weapon (pens,
shears, stethoscope, badge lanyard)
• Always have an exit
• Show of force
Physical Violence • Never acceptable
• Protect yourself above all else
• RUN!
• Know how to get your team (If unexpected
violence)

31. Remember
1. Violence and aggression are not acceptable in the
Emergency Department
2. If there is an issue, let someone know

32. Legal & Ethical Issues in Critical
Care Units

33. Legal vs Ethical
Legal Issues Ethical issues
• Unlicensed Assistive Personnel
• HIPAA
• Consent
• Reportable Conditions
• Documentation
• Restraints
• Advance Directives
• Forensics
• Violence and workplace safety
• Code of Ethics
• Advance Directives
• DNR
• Informed consent or refusal
• AMA & LWOT
• Minors
• Triage

34. Reportable Conditions
State specific
Falls
Medication Errors
Abuse (Child or elder)
Failure to inform

35. Documentation
If it wasn't documented, it wasn't done!
Legal document
Joint Commission requirements
Unapproved abbreviations

36. Restraints and Advanced Directives
Restraints
Duty to restrain
False imprisonment
Continuous assessments
Advanced directives
Living will
Power of Attorney
DNR

37. Forensics
Evidence collection
Criminal
Sexual Assault
ME Cases
Trauma
Unexpected or unexplained death
Violence and workplace safety

38. Ethical Issues and Consideration
Code of Ethics
◦ Developed by the ANA in 1950
◦ Updated in 2001
◦ ENA Provisions for ED Nurses
Advance Directives
◦ Power of attorney
◦ Living will
◦ DNR
◦ Documentation – Act until proven otherwise

39. Ethical Issues and Consideration
Informed consent or refusal
◦Do they understand the following;
◦ What we are going to do
◦ How we are going to do it
◦ What it is going to do to them
AMA & LWOT
◦Competency
◦Do they understand the risks?
◦Can they repeat their understanding of the consequences?

40. Ethical Issues and Consideration
Minors
◦Childs best interest
◦CPS intervention
Triage
◦Who gets seen first?
◦Who gets the last ICU bed
◦Mass Casualty: In mass casualty events, people we would normally try to
save, we have to bypass. We need to do the greatest good for the greatest number of
people and it may require some hard decisions we normally would not make.

41. EMTALA and Transfers

42. Ethical Issues and Consideration
The Emergency Medical Treatment and Active Labor
Act (EMTALA) was designed in order to protect
patients in the emergency department. It is now law
and failing to meet its requirements can result in legal
proceedings. It was designed for Medicare receiving
facilities but its policies and procedures have become
the standard of care in many Emergency
Departments.

43. What is EMTALA?
Emergency Medical Treatment and Active Labor Act (1986)
Response to treatment refusals or transfers out due to inability to
pay
Law for Medicare providing institutions – Standard of care
elsewhere

44. How does it apply?
Predetermined set of regulations – Items that must
be done
◦Medical screening
◦Stabilizing treatment
◦Transfer regulations

45. Interfacility Transfer
A. Risk vs benefit
B. Criteria for transfer
◦ Higher level of care
◦ Specialty care
C. Requirements for a transfer
◦ Transfer agreement
◦ Written informed consent
◦ Documentation that facility can receive
◦ Accepting Physician
◦ Appropriate transfer method and resources
◦ Inclusion of all paperwork for transfer

46. Interfacility Transfer
Nurse’s Role
Assist in stabilization (or a stable as needed for transport)
Assure all paperwork is in order
Give report to receiving facility
Speak with family
Give report to transport team
Continue to assess patient until care handed off
Document, Document, Document

47. Patient Teaching
Patient Education
There may be instances when you or your loved
one will need to be transferred from their original
hospital.
Transfers are done from the ED in order to give the
best possible care.

48. Cardiovascular Emergencies

49. Overview-ACS (acute coronary syndrome)
Acute Coronary Syndrome includes the continuum of
Unstable Angina, non-ST segment elevation
myocardial ischemia (NSTEMI) and ST segment
elevation myocardial ischemia (STEMI). The different
syndromes refer to different levels of ischemia
occurring and differing oxygen demands.

50. Assessment-ACS
A. Differences between males and females
B. OLDCARTS – P
I. Onset
II. Location
III. Duration
IV. Characteristics
V. Aggravating Factors
VI. Relieving Factors
VII. Treatment
VIII. Severity
IX. Prior History
Diagnostic Tests
• 12-lead EKG
• Cardiac Enzymes

51. Therapeutic Management-ACS
Old Way: MONA
I. Morphine
II. Oxygen
III. Nitro-glycerine
IV.Aspirin
New Way
Holding Morphine, Nitro, or O2 for certain patients
Morphine – yes for STEMI, caution with angina and NSTEMI
Nitro – In STEMI, can cause drug induced hypotension and worsen ischemia

52. Outcomes-ACS
A. Angina – Nitro and observation
B. NSTEMI – Medication management – Beta Blockers,
platelet aggregators (aspirin, Plavix)
C. STEMI – Cath lab for Percutaneous coronary intervention
(PCI): If unable to get to Cath within 90-120 minutes,
consider fibrinolytics

53. Aneurysms & Dissection
Aneurysms are dilations or outpouchings of a blood
vessel due to weakening of the walls. They are most
commonly caused by hypertension. Dissections are
rips or tears in the vessels that require immediate
surgical intervention to prevent mortality..

54. Description
1. Cerebral Aneurysm
Leading cause of non-traumatic Sub Arachnoid Haemorrhage
2. Aortic Aneurysm
Thoracic
Abdominal
3. Aortic Dissection
Signs and symptoms
Therapeutic interventions

55. Assessment
Cerebral Aneurysm / rupture
Sudden, intense, unrelenting headache
Altered loss of consciousness
Photophobia
Nuchal rigidity
Nausea or vomiting
◦ Get Head CT to identify location and severity

56. Assessment
Aortic Aneurysm
Thoracic
1. Pain in back, shoulders, abdomen
2. Dyspnea
Abdominal
1. Pulsating mass in the abdomen
2. Systolic bruit over abdomen
3. Tenderness on abdominal palpation
4. Hematoma on flank

57. Assessment
Aortic Dissection
Classic signs of dissection
I. One arm with low or no BP
II. Pale or pulseless lower extremities
III. Severe ripping or tearing chest pain radiating to back
or abdomen
IV. Pain difficult to relieve
V. Altered level of consciousness
VI. Pale, gray, diaphoretic

58. Assessment
For any suspected Aortic involvement –
Chest radiograph – can reveal widened
mediastinum
Transthoracic echocardiogram to visualize
dissection
Chest CT or Chest CTA

59. Therapeutic Management
Cerebral Aneurysm/Rupture
Airway and O2 are priority especially with a decreased or demising
LOC
Initial treatment aimed at preventing further bleeding
◦ Maintain SBP between 90-140 mmHg
◦ Admin IV pain meds
◦ Benzos?With that crazy pain, we want to give some IV pain meds. And with that pain, can come
increased anxiety so we might want to consider some IV benzos as well.
Neuro assessments
Possible ICP monitoring
If rupture, emergent OR for craniotomy

60. Therapeutic Management
Reduce blood pressure
Decrease pressure on weak vessel
Maintain adequate MAP for perfusion of vital
organs
Surgical Options
Abdominal aortic aneurysm resection
EVAR (endovascular aneurysm repair)

61. Therapeutic Management
Aortic Dissection
A. O2 and 2 large bore IV
B. Assess BP in both arms
C. Admin Nitroprusside or Nitro-glycerine for vasodilation
D. IV bet-blockers to decrease contractility
E. Pain Medication
F. Surgical repair – possible need for cardiopulmonary bypass
(anticipate possible transfer)

62. Patient Teaching
Patient Education
Unrelenting and sudden pain to head
or chest requires immediate investigation
from a physician

63. Cardiopulmonary Arrest
I. Recognize sudden cardiac death
II. Activate emergency response team (Call the
code)
III.Perform high-quality chest compressions
IV.Begin rescue breathing / establish airway
V. Perform rapid defibrillation

64. General Considerations
Remember your BLS / ACLS algorhythms
4 rhythms cause cardiac arrest
◦Ventricular Fibrillation (V-FIB)
◦Ventricular Tachycardia (V-TACH)
◦Pulseless Electrical Activity (PEA)
◦Ventricular Asystole
◦ Compressions for all, Defib for some
Know your team, know your role!

65. Assessment
I. Establish unresponsiveness
II. Absence of breathing (Look, listen, feel)
III. Absence of pulse (Carotid or femoral)
IV. Determine EKG rhythm

66. Therapeutic Management
1. Chest Compressions
2. Airway Control
3. Breathing and Circulation
4. IV Access (peripheral, IO or Central)
5. Defibrillate
Drugs
 Epinephrine
 Vasopressin
 Amiodarone
 Fluids

67. Therapeutic Management
Treat Reversible Causes (H’s and T’s)
◦ Hypoxia
◦ Hypovolemia
◦ Hydrogen Ion (acidosis)
◦ Hypothermia
◦ Hypo / Hyperkalemia
◦ Toxins (including overdose)
◦ Tamponade
◦ Tension Pneumothorax
◦ Thrombosis

68. Patient Teaching
Patient Education
If you suspect cardiac arrest, start chest
compressions and call 911
Take a CPR class when you can

69. Dysrhythmia
Cardiac dysrhythmias can cause alterations in heart rate and
cardia output. While the outcomes may be similar, the
treatments are very different.
General points:
Symptomatic Bradycardia
◦ Slow Heart rate = lower cardiac output
Supraventricular Tachycardia
◦ Fast Heart Rate (like super fast) = decreased coronary perfusion,
decreased filling time, decreased stroke volume = decreased cardiac
output

70. Symptomatic Bradycardia
Chest pain
Shortness of breath
Decreased LOC
Lightheaded, dizzy, syncope
Hypotension

71. Supraventricular Tachycardia
Palpitations
Chest Pain
Shortness of breath
Diaphoresis
Poor peripheral pulses
Anxiety
Syncope
Diagnostics
• 12-lead EKG
• Brady – HR less than 60
• SVT – HR 150-300 (Told
you, super fast)

72. Therapeutic Management
Symptomatic Bradycardia
Lets speed things up
IV access
Get that 12 lead
Prepare for transcutaneous pacing
Meds – Atropine, Epinephrine, Dopamine
Supraventricular Tachycardia
 Let’s slow it down
 Vagal Manoeuvre
 Meds – Adenosine (for regular rhythm), Diltiazem or beta-blockers (if irregular)
 Synchronized Cardioversion (if hemodynamically unstable)

73. Patient Teaching
Patient Education
Palpitations of any sort should be checked out by a
physician
Any change in level of consciousness should be
checked out. Could be a brain problem. Could be a
heart problem. We can’t tell from outside the hospital.

74. Heart Failure
Identifying these patients when they hit the ED doors is vital
to their treatment. Getting a thorough history can help to
determine their treatment and subsequent recovery plan.

75. Assessment
Try to determine cause:
◦Acute coronary syndrome
◦Uncontrolled hypertension
◦Cardiomyopathies
◦Valvular dysfunction
◦Cardiac infections
◦Noncompliance with diet and medications (that darn Chinese
food!): This is one I see most commonly, is the patient
noncompliant with their medications or their diet. It is
amazing what a little Chinese food can do to grandma's heart.

76. Assessment
Right Sided Exacerbation
A. Peripheral Edema
B. Jugular Venus Distention (JVD)
C. Ascites
D. Nausea secondary to abdominal venous congestion

77. Assessment
Left Sided Exacerbation
A. Shortness of Breath
B. Dyspnea
C. S3 Heart Sound
D. Crackles
E. Pulmonary Edema

78. Therapeutic Management
1. ABCs are always first priority
◦ Admin supplemental Oxygen
2. IV access
3. BiPAP
4. IV Meds
Loop diuretic (Lasix)
Morphine
Nitro-glycerine or Nitroprusside
Ace Inhibitors
5. Continued monitoring
Lung Sounds
BP and HR
LOC
Urine output

79. Patient Teaching
Patient Education
• Emphasize importance of tasking prescribed
medications
• Review proper dietary restrictions (low
sodium!)

80. Hypertensive Emergencies
Hypertensive emergencies, or hypertensive crisis, is present in
patients with a systolic blood pressure of over 180 mm Hg or a
diastolic of over 120 mm Hg and evidence of impending organ
damage.
NOTE:
Vital signs alone can not determine if a patient’s
hypertension is a life-threatening emergency. We
need to be able to identify signs and symptoms of
end-organ damage and treat the underlying causes.

81. Assessment for hypertension
1. Vital signs…obviously need the BP
2. Signs of Cerebrovascular impairment
Headache
Altered LOC
Confusion
Seizure
3. Cardiovascular compromise
Chest Pain, changes on EKG
Symptoms of heart failure

82. Assessment for hypertension
1. Retinopathy
Hemorrhage
Papilledema
2. Renovascular impairment
Hematuria
Decreased urine output
3. Other
Epistaxis
Blurred Vision
Diagnostics
• Urinalysis
• BUN and Cr to assess
kidney damage
• 12-lead EKG
• Chest X-Ray
• Head CT

83. Therapeutic Management for
hypertension
Admin O2 and get IV access
Continuous BP monitoring (every 5 minutes)
1. Check both arms
2. May require an arterial line
Sublingual or IV nitroglycerin
IV nitroprusside
IV labetalol
1. Limit the decrease in BP to 20% in the first 24 hours to prevent
relative hypotension
Continuous monitoring, especially LOC

84. Patient Teaching
Patient Education
• Check blood pressure regularly if history of
hypertension
• If you have strange symptoms, get checked, do
not hesitate.

85. Arterial Pressure Monitoring
An arterial catheter or Art line is a method of monitoring
arterial blood pressure through an artery, it can also be used
to draw ABGs and blood labs.

86. General Points for arterial BP monitoring
Arterial lines
1. Inserted by MD/PA/NP
2. Radial artery: Most common
3. Measures the arterial blood pressure
4. MAP = >65
5. Indications
◦Hemodynamically unstable
Meds to titrate
◦Surgery (Coronary artery bypass graft)

87. General Points for arterial BP monitoring
Monitoring
1. Ensure the transducer is leveled to the patient’s
phlebostatic axis
2. SPO2 on the same hand as art line

88. General Points for arterial BP monitoring
Arterial Waveform
1. Corresponds with the cardiac cycle on an EKG
2. Begins after the ventricles have depolarized
3. Sharp upstroke: Ventricular systole
4. Downstroke: Drop in systolic pressure
5. Dichotic Notch: Closure of aortic valve
6. Descending slope: Beginning of diastole
7. Lowest point of waveform: End diastolic pressure or
preload

89. Assessment for arterial BP monitoring
1. Damping/Damped: Fluid or position can affect readings
2. Underdamped
Higher more peaked waveforms
Falsely elevated BP
Air in tubing/longer lose tubing
3. Overdamped
Smaller waveform
No dichotic notch
Falsely low pressures
Clots at the tip of the catheter obstructing flow

90. Respiratory Emergencies

91. Rapid Sequence Intubation (RSI)
Endotracheal intubation using rapid sequence intubation
(RSI) is the cornerstone of emergency airway management.

92. Assessment-RSI
Indications
1. Airway protection
2. Respiratory failure
3. Shock
4. Intracranial Hypertension
5. Reduce the work of breathing

93. Assessment-RSI
Who needs to be there?
1. Physician (ED) or 2 or 3
2. Nurse, or 2 or 3
3. Respiratory Tech
4. PCAs

94. Assessment-RSI
What do we needs?
Equipment
Medications
Sedative
Anesthesia
Paralytic

95. Assessment-RSI
What do we need after?
1. Sedation
2. Safety equipment

96. Therapeutic Management-RSI
The Nurses Role
1. What can we push-Draw the drugs-most states allow nurses
to push medications like Etomidate and succinylcholine but
frown on pushing propofol.
2. Bagging the patient
3. Verification of placement
4. Monitoring Saturations
5. Ordering Chest x-ray
6. Post-sedation care

97. Patient Teaching
Patient Education
• If the patient is conscious, explain to them
what is going to happen.

98. Assessment-PE
Signs and symptoms
1. Often non-specific
2. Dyspnea, Tachypnea, haemoptysis
3. Sudden onset pleuritic chest pain
4. Tachycardia
5. Anxiety
6. Signs of DVT
7. Atypical signs

99. Diagnostic Tests
1. Chest X-Ray
2. ABG
3. D-Dimer (This is usually done to determine the possible
presence of a PE. Usually if its below 500, then you are safe.
Over 500 doesn't mean that the PE is definitive)
4. Ultrasound of leg
5. Spiral CT
6. MRI / MRA
7. !2-Lead (rule out)
8. Coagulation studies

100. Therapeutic Management
The Basics
1. Supplemental O2
2. IV Access
3. Vitals (O2 sat, capnography)
Heparin therapy
IV tPA or angiographic intervention

101. Patient Teaching
Patient Education
• Explain the risk factors and symptoms.
• Tips for preventing PE:
1. Mobility during travel
2. Smoking cessation

102. Acute Respiratory Distress Syndrome
(ARDS)
Asthma and COPD exacerbations account for over 3 million
combined ED visits each year. The prevalence of these
conditions warrants more education as to their
identification and treatment.

103. Assessment-ARDS
Asthma: Symptoms
1. Wheeze
2. Cough
3. Accessory muscle use
4. Anxiety
5. Inability to speak
6. Diminished or absent breath
sounds
COPD: Symptoms
1. Dyspnea, Tachypnea,
Hypoxemia
2. Change in sputum
3. Ronchi, wheezes, crackles
4. Pursed lip breathing
5. Accessory muscle use
6. Cor pulmonale
7. JVD
8. Hepatomegaly

104. Therapeutic Management-Asthma
1. Position of comfort
2. Determine duration
3. Previous exacerbations (intubations?)
4. O2
5. IV Access
6. Inhaled nebulized meds
◦ Albuterol
◦ Atrovent
◦ Peak Flow
◦ Steroids
7. Magnesium Sulfate
8. Intubation

105. Therapeutic Management-Asthma
1. Monitor Pulse oximetry (90%-92%)
NEVER WITHHOLD OXYGEN
2. Nebulized meds
◦ Albuterol
◦ Atrovent
3. IV Access
4. BiPAP Therapy
5. Steroids and antibiotics
6. High Fowlers position, Position of comfort

106. Patient Teaching
Patient Education
• For both conditions, treat prevention. Avoid
triggers.

107. Neurological Emergencies

108. Acute Confusion
With a patient who is acutely confused, a thorough history
is vital to determining their baseline status and in turn,
attempting to return them to that state.

109. Assessment-Acute Confusion
What is acute confusion?
◦ Confusion Assessment Method (see notes below)
Differential diagnosis identification-AEIOU-TIPS
◦ A – Alcohol (intoxication or withdrawal)
◦ E – Epilepsy (or any seizure)
◦ I – Insulin (too much or too little)
◦ O – Oxygen (Under or overdose)
◦ U – Uraemia (or other metabolic issues, i.e. UTI)
◦ T – Trauma, Toxicity, Tumor, Thermoregulation
◦ I – Infection, Ischemia
◦ P – Psychiatric, Poisoning
◦ S – Stroke, Syncope (neuro or cardio issue)

110. Therapeutic Management-Acute
Confusion
Treat the underlying cause-AEIOUTIPS
◦ A – Alcohol (intoxication or withdrawal): Detox or prevention of withdrawal
complications
◦ E – Epilepsy (or any seizure): Stop the seizure, wait for return to baseline
◦ I – Insulin (too much or too little): Give more or treat the hypoglycemia
◦ O – Oxygen (Under or overdose): Take it off or put it on
◦ U – Uremia (or other metabolic issues, i.e. UTI): Antibiotics, fluids
◦ T – Trauma, Toxicity, Tumor, Thermoregulation: Treat the appropriate “T”
◦ I – Infection, Ischemia: Antibiotics, fluids for infection and clear the blockage
◦ P – Psychiatric, Poisoning: Medicate, consult the experts
◦ S – Stroke, Syncope (neuro or cardio issue): Consult the experts and treat the
cause

111. Patient Teaching-Acute Confusion
Patient Education
Any change in mental status should be investigated
An acute change in mental status requires evaluation so come
to the emergency department
Acute confusion, especially in the elderly, may be easily
diagnosed and treated, but can lead to serious complication if
it is not identified

112. Overview-Intracranial Hemorrhage
While subdural and epidural hematomas are both injuries
involving bleeding on the brain, their presentation, and
subsequent treatment can be significantly different.

113. Assessment-Intracranial Hemorrhage
Subdural Bleed Epidural Bleed Both
1. Headache
2. Progressive loss of
consciousness
3. Fixed and Dilated (first one
then both)
4. Abnormal Respirations
5. Contralateral hemiparesis
6. Increased ICP
7. Nausea/Vomiting
1. Severe Headache
2. Agitation
3. Sudden of progressive loss of
consciousness
4. Lights out! –> Lights on! –>
Lights out!
5. One dilated pupil
6. Contralateral weakness
7. Bradycardia
8. Increased BP
9. Abnormal Respirations
1. Serial neuro exams – GCS
2. Monitor ABCs
3. Monitor ICP with GCS of 8 or
less and abnormal CT
1.Tell difference between a subdural and epidural bleed with initial presentation
2.Urgency for each

114. Therapeutic Management-Intracranial
Hemorrhage
For both:
Serial neuro exams – GCS if less than 8 – intubate
Maintain O2 sat greater than 95%
Avoid hyperventilation
Restore fluid volume as needed
Foley Cath (0.5 to 1 mL/Kg an hour)
CT scan: Monitor ICP with GCS of 8 or less and an abnormal CT: Reduce ICP if needed, facilitate
surgical intervention
Subdural Bleed: Surgical evacuation or burr holes with gradual drainage
Epidural Bleed: Emergent surgical evacuation
Likely ER interventions or what
the nurse should anticipate:
subdural may just get CT and
monitoring if small, epidural
may go straight to OR for
evacuation/cautery

115. Patient Teaching-Acute Confusion
Patient Education
Identifying signs of head injury
Get the victim to a hospital, time is of the essence

116. Increased Intracranial Pressure (ICP)
Trauma, stroke, hypertension, and infection are just some of
the ailments that can cause an increase in intracranial
pressure. Signs and symptoms such as altered LOC, nausea
and vomiting, seizures, headaches, focal deficits, and
anisocoria are just some of the clues that our patients ICP is
rising.

117. Assessment-Increased ICP
Early Signs
• Health Assessment
• Nausea/Vomiting
• Amnesia
• Behaviour Changes
• Altered LOC
Late Signs
• Dilated, Nonreactive Pupils
• Unresponsiveness
• Posturing
• Cushing's Triad: Bradycardia,
Hypertension (Systolic),
Irregular respirations (low)

118. Assessment-Increased ICP
Serial neuro assessment
Glasgow Coma Scale
• Verbal Response 1-4
• Eye Opening 1-5
• Motor Response 1-6
Pupillary assessment
• Anisocoria
Reflex assessment
• Decorticate Posturing
(the forearms are
pulled towards the
center of the chest)
• Decerebrate
Posturing (the arms
are straight at the
sides and the wrists
and hands are facing
out)

119. Causes-Increased ICP
Trauma
Intercranial Hemorrhage
Ruptured Aneurysm
Hydrocephalus
Tumors
Cerebral Edema

120. Therapeutic Management-Increased ICP
Reduce Intracranial Pressure
1. Sedation and analgesia
2. Osmotic Diuretic
3. Positioning
4. Decrease Stimulation
5. Take off that Cervical Collar
6. Insertion of ICP monitor
7. Possible ventriculostomy in ED
8. Prepare for emergent surgical decompression

121. Patient Teaching-Acute Confusion
Patient Education
 Signs of a change in mental status
 Stress importance of not ignoring warning signs. If
you don't know….seek emergency IMMIDIATELY

122. Stroke (CVA) Management
Time and type are of the essence when it comes to stroke
identification and treatment in the emergency department.
When the symptoms started and whether the stroke is
ischemic or hemorrhagic are the two most important details
in determining the plan of care

123. Assessment-Stroke
Presentation
EMS Pre-notification: Stroke Note – allows ED to preactivate
Stroke Team with proper information
FAST
Facial droop
Arm Drift
Speech Problems
Time – (time is tissue)
When did the symptoms start – needs to be certain

124. Assessment-Stroke
Baseline
1. What is the patients normal activity and mental
status?
2. Comorbities: Diabetes, Active UTI, Other brain
disorders (hydrocephalus, tumor, etc.)
Time of onset
1. We mention this twice because its that
important

125. Assessment-Stroke
NIH Stroke Scale
1. Measurements of:
2. Level of consciousness
3. Horizontal eye movement
4. Visual fields
5. Facial palsy
6. Arm and leg motor function
7. Sensation
8. Language and speech
9. Neglect and inattention
Total score of all assessments can range from 0-42: The higher the score – the worse the situation

126. Assessment-Stroke
Differentials
1. Finger Stick: Hypoglycemia?
2. Urine Sample: UTI?
3. Other Blood Work: Other metabolic
disorders? hyponatremia, hypercalcemia,
sepsis, even something like a bad case of
the flu, can all manifest symptoms that we
could mistake for stroke.

127. Therapeutic Management-Medical
Ischemic
1. tPA (Tissue Plasminogen Activator / Alteplase) – THE CLOT
BUSTER
2. Can be mixed in the unit or by pharmacy
3. IV infusion – Bolus then drip
4. Percutaneous Thrombectomy: Go in and get it!

128. Therapeutic Management-Medical
Hemorrhagic
1. Ventriculostomy / EVD: drilling some holes in the skull)
and placing an extra ventricular drain to allow for gradual
drainage.
2. Craniotomy: If its more severe, they may require a
craniotomy to remove a piece of the skull to allow for
more immediate drainage and decompression.

129. Therapeutic Management-Medical
Time Line and Goals
Door-to-doc: 10 Minutes
Door-to-Stroke team notification: 15 Minutes
Door-to-CT Scan: 25 Minutes
Door-to-CT read: 45 Minutes
Door-to-tPA: 60 minutes
tPA should be within 3.5-4 hours of onset of symptoms

130. Therapeutic Management-Nursing
Intracranial Regulation: Maintaining proper ICP
Perfusion: Reperfuse with tPA or reduce ICP with surgical
procedures
Prioritization: All about time of receiving care

131. Patient Teaching-Acute Confusion
Patient Education
 FAST
• Facial droop
• Arm Drift
• Speech Problems
• Time – (time is tissue)
 If there is any suspicion of possibility of a stroke… do
not hesitate, call 911!

132. Seizures
While seizures can be expected in a disorder such as
epilepsy, there are numerous other causes that will roll
through the doors of the emergency department. Add to
that, the fact that our typical tonic-clonic seizure is just one
of several types we need to identify and treat, and our
critical thinking becomes our most valuable tool.

133. Causes-Seizures
Seizure disorder / Epilepsy
Trauma
Hypoxia
Stroke
Hypoglycemia
Hypo/hypernatremia
Infection
1. Meningitis
2. Encephalitis
3. Brain Abscess
Special Concerns: Eclampsia, alcohol Withdrawal, drug Induced

134. Assessment-Seizures
Generalized Tonic Clonic
Also called – Grand Mal
LOC and Loss of muscle tone
Extensor muscle spasms
Irregular respirations or apnea
Followed by postictal phase
Partial Seizures
Also called focal seizures, Jacksonian, Psychomotor, or Minor Motor
Usually unilateral
No LOC
Activity lasting less than 5 minutes – rarely requires meds.

135. Assessment-Seizures
Febrile Seizures
◦ AKA…..febrile seizures
◦ Caused by a rapid rise in body temp
◦ Usually seen in infants and pediatrics
◦ Treatment aimed at patient safety while lowering the fever
Status Epilepticus
◦ Series of consecutive seizures without return to normal LOC or
◦ a single seizure lasting more than 5 minutes that does not resolve without
intervention
◦ Medical emergency
◦ Results in acidosis, hypoglycemia, hypercalcemia, muscle damage, and in turn,
morbidity and mortality.

136. Documentation of Seizures Findings
COLD mnemonic
C – Character – What type of seizure occurred?
O – Onset – When did it start? What was the patient
doing?
L – Location – Where did the activity start?
D – Duration – How long did the seizure last?

137. Therapeutic Management
ABCs
1. Admin O2
2. Intubate if in Status Epilepticus
Prevent injury
1. Seizure precautions: Facility specific

138. Therapeutic Management-Medical
Benzodiazepines (Stop the seizure)
1. Ativan (Lorazepam) – 2mg IV
2. Valium (Diazepam)
3. Phenobarbital
Anticonvulsants (Prevent more seizures)
1. Dilantin (Phenytoin)
2. Cerebyx (Fosphenytoin)
3. Keppra (Levetiracetam)
4. Metabolic replacements
50% dextrose water (D50) (see notes below)
1. To correct hypoglycemia
2. Give 50-100mg thiamine IV to alcoholics prior to D50 to prevent Wernicke-Korsakoff.

139. Post-Ictal Phase
After the seizure has ended, the patient will be in their
postictal phase. They will usually be confused and it's our
job to provide for their safety. Be aware that these patients
can be very agitated and even combative, which can
manifest in physical violence.
1. Provide safety over time
2. Be alert for agitation or combativeness: Patient will be
unaware and unable to control actions

140. Patient Teaching-Acute Confusion
Patient Education
 If you are witnessing a seizure, make sure the patient
is safe.
 Clear away anything they can strike
 Never put anything in their mouth

141. Thank You