NCM 118- LEC: Nursing Care of Clients 5.

Enumerate different
with Life Threatening Conditions, Acutely Ill pharmacologic management
or Multi Organ Problems, High Acuity and including its nursing interventions
Emergency Situations, Acute and Chronic. 6. Discuss different surgical and
special procedures

Objectives
ACUTE BIOLOGICAL CRISIS
1. Assess client with ABC using
• Condition that may result to patient
standard assessment of the ill.
mortality if left unattended in a brief
• Focused history taking
period of time.
• Discriminating PE (A-B-C)
• Condition that warrants immediate
2. Enumerate different
attention for the reversal of disease
diagnostics/laboratory data
process and prevention of further
• Non-invasive: ECG , cardiac
morbidity and mortality.
rhythms
• Invasive: ABG,
hemodynamic monitoring CRITICAL CARE NURSING
3. Formulate nursing diagnoses
• Nursing specialty that deals
taxonomy pertinent to ABC
specifically with human responses to
4. Identify different treatment
life-threatening problems.
modalities
• A Critical care nurse is a licensed
• Life saving interventions
professional nurse who is responsible
• Life maintaining
for ensuring that acutely and critically
interventions
ill patients and their families receive
• Psychosocial and behavioral optimal care.
interventions
Critically ill patients are those
• Supportive management
patients who are at high risk for actual or
• Prevention of complications
potential life-threatening health
• Rehabilitation
problems. The more critically ill the
patient is, the more likely he/she is to be
 highly vulnerable, unstable and complex, Goals of assessing medical patients
thereby requiring intense and vigilant
• Explore and characterize the patient’s
nursing care.
main health concern.
• No need to go into each item of
critical background history in great
THE FOCUS OF CRITICAL CARE
detail, but should briefly touch on
NURSING
each item or at least consider them
Goal of critical care nursing
• Differentiate between critical &
• To provide comfort and facilitate noncritical conditions
healing of patients whose lives are • Gather focused history & choose
under threat from illness or trauma, appropriate assessment
whether sudden or chronic, accidental
or surgical.
FOCUSED HISTORY & PE: MEDICAL
• Critical illness influences all body
1. Scene size-up
systems and has a profound impact on
2. Initial assessment
the people it affects
3. Focused history & physical exam
4. Rapid assessment
ASSESSMENT
5. Vital signs (VS)
• Focused History/PE 6. Ongoing assessment

• Comprehensive History/ PE

SCENE SIZE-UP
FOCUSED HISTORY/PE • BSI (Body Substance Isolation)
Taken in 8-14 minutes that addresses the precautions
patient’s presenting health issue. • Evaluating scene safety
• Determining the MOI/NOI
• Determining the total number of
patients
• Determining the need for additional
resources
INITIAL ASSESSMENT Chief Complaint

• Initial impression What patient states in his/her own

• Mental status words is primary problem.
• ABCs OPQRST EMS ACRONYMS
• Assign priority
• ONSET = What was the patient doing
• Stable
when the signs and symptoms first
• Unstable
occurred? Was the onset sudden or
• Treatment & transport decisions
gradual?
• Sequence depends on patient’s
• PROVOCATION OR
condition
PALLIATION = Is there anything
Components that makes the symptom better or
worse?
• History of present illness
• QUALITY = Description of what the
• Assessment of complaints, signs,
patient is feeling. For example, the
symptoms (OPQRST = Onset,
pain can be described as dull, sharp,
Provocation, Quality, Radiation,
crushing, aching, tearing, throbbing,
Severity, and Time)
etc.
• SAMPLE history
• REGION AND RADIATION =
• Rapid assessment
Where is the pain located and does it
• Baseline VS
move to another part of the body?
• Emergency medical care
• SEVERITY = How severe is the
symptom based on a scale of 1 to 10?
A. HISTORY OF PRESENT • TIME = When did the signs and
ILLNESS symptoms first occur?
• Why was EMS called?
• Elaboration on chief complaint
B. MEDICAL PATIENT ✓ Head-to-toe order
ASSESSMENT ✓ Focused assessment for responsive
patients
OPQRST - important for qualifying patient
✓ Unresponsive patients
conditions
✓ Head
• Pain ✓ Neck
• Respiratory difficulties ✓ Chest
• Altered mental status ✓ Abdomen
• Allergic reaction ✓ Pelvis
• Poisoning/overdose ✓ Back
• Environmental emergencies ✓ Extremities
• Obstetric conditions
Trauma
• Behavioral emergencies/psychiatric
• DCAPBTLS - Deformities,
emergencies
Contusions, Abrasions, Penetrations,
Burns, Tenderness, Lacerations,
C. SAMPLE HISTORY
Swelling
• Signs & symptoms Medical
• Allergies
• Function
• Medications
• Guarding
• Past medical history
• Masses
• Last oral intake
• Pain
• Events leading up to episode
• Tenderness

D. RAPID ASSESSMENT E. VITAL SIGNS

• Conscious patients - history first • Baseline
• Critical/unstable patients - history • Trending with multiple sets
& assessment simultaneously ✓ Changes in condition
• Unresponsive patients - assessment ✓ Response to treatment
first, then history
F. EMERGENCY MEDICAL CARE

• When assessment is complete, plan or

initiate care
• Care should be focused on signs &
symptoms

Unresponsive medical patient

• Rely on patient’s presentation &

information from bystanders/family
• Pay attention to environment for clues
• Consider ACLS intercept(clinical
interventions for urgent emergencies)

ABC: MEDICAL EMERGENCIES

1. Cardiac Failure
2. Acute MI
3. Acute Respiratory Failure
4. Acute Renal Failure
5. Stroke
6. Increased ICP
7. Metabolic emergencies (DKA,
HHNK)
8. Massive Bleeding
9. Extensive Surgeries
10. Extensive Burns
11. Poisoning
12. Multiple Injuries
13. Emerging Diseases (SARS, Avian
Flu, Corona Virus, COVID-19)