BASIC DHS for Nurses

Authors
Aurélia Rapin, Aurélie Godard, Yves Wailly, Sarah Woznick, Rochelle DeLacey, Georges Edouard Seide,
Anne-Constance Sartiaux, Patient Kighoma,
Médecins sans Frontières, Paris

Elizabeth Barrett
Intensive Care Unit, Nepean Hospital, Australia

Charles Gomersall
Dept of Anaesthesia & Intensive Care, The Chinese University of Hong Kong

Illustrator
Janet Fong
Dept of Anaesthesia & Intensive Care, The Chinese University of Hong Kong

Copy editor
Carolyn Gomersall

BASIC steering committee

Charles Gomersall, Gavin Joynt, Ross Freebairn, Richard Leonard, Robert Boots, Shanti Deva, Pravin Amin,
Du Bin, Hussain Nassar Al Rahma, Shivakumar Iyer, Subhash Todi, Hans Flaatten, Mary Pinder, Pascale
Gruber, Rui Moreno, Gordon Choi, Bruce Lister

August 2015

Developed by Médecins sans Frontières, Paris and the BASIC Collaboration

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BASIC DHS for Nurses

Publisher
Published by the Dept of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Shatin, Hong
Kong.

The copyright is the property of the individual authors and illustrators.

Potential conflict of interest

In 2014 the Department of Anaesthesia & Intensive Care of The Chinese University of Hong Kong received
educational, research or travel grants for Intensive Care related activities from: Astellas, Dräger, Fischer &
Paykel, Maquet and Pfizer.

Disclaimer
The management strategies outlined in the manual represent the views of the contributors. They are by no
means the only way of managing seriously ill patients and may not necessarily be the best. Although the
content of the manual is believed to be accurate the contributors and their institutions take no responsibility for
any adverse event resulting from the use of the manual or for the quality of courses run by third parties.
Readers are advised to check doses of drugs from the relevant manufacturers’ data sheets.

Acknowledgements
The authors would like to thank Xavier Lassalle, Kelly Dilworth, Michelle Van Den Berg, Benoit Kervyn,
Monique Gueguen, Estrella Lasry, Anne-Sophie Castex, Miho Saito for their helpful comments on the
manuscript.

About the BASIC Collaboration

BASIC Collaboration course materials are provided free of charge to course organizers on the condition that
any profit from courses is used for Intensive Care education or research. Details of our courses can be found
at http://www.aic.cuhk.edu.hk/web8/courses.htm.
BASIC Collaboration courses have been held in over 50 countries.

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Contents
Emergency assessment .......................................................................................................... 5
Acute respiratory failure ........................................................................................................ 21
Cardiology ............................................................................................................................. 47
Shock..................................................................................................................................... 55
Neurology .............................................................................................................................. 63
Pain management ................................................................................................................. 79
Nutrition ................................................................................................................................. 89
Blood transfusion................................................................................................................... 95
Trauma .................................................................................................................................. 99
Burns ................................................................................................................................... 109
Obstetric care ...................................................................................................................... 117
Post-operative care ............................................................................................................. 123
Transport ............................................................................................................................. 131
Severe malaria .................................................................................................................... 133
Nursing assessment ............................................................................................................ 135
Nursing care ........................................................................................................................ 141
Infection control ................................................................................................................... 145
Communication within the healthcare team and clinical handover ..................................... 153
Communication with patients and families .......................................................................... 161
Palliative care ...................................................................................................................... 163
Appendix 1 – triage ............................................................................................................. 167
Appendix 2 – oxygen cylinders ........................................................................................... 169
Appendix 3 – post partum haemorrhage............................................................................. 170

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 Emergency assessment

Emergency assessment
One of the most important skills a nurse needs to be able to perform well is patient assessment. It is not
enough to only know the techniques – the critical care nurse must know how to organize an assessment
according to the patient and the situation.

Seriously ill patients often need urgent treatment to prevent death, and you might not have time to make a
complete assessment before starting this treatment:
 Look at the patient’s overall appearance, as this will often give you a clue.
 -If the patient has any danger signs (refer to Warning signs of severe illness adults table in triage part ),
urgent treatment is necessary

The emergency assessment is a quick assessment used to evaluate the patient’s vital functions and identify
and treat any potentially life-threatening conditions that require immediate medical attention. ABCDE (airway,
breathing, circulation, disability, exposure/environment), can be used to help you remember the important
functions that need to be assessed quickly

We will go through each one in detail below. This section should be used both for the immediate, first
assessment on arrival in hospital and to reassess sick patients in hospital, or waiting in the emergency
department.

Never leave any critically ill patient with an unsolved medical disorder alone – stay with the
patient and never hesitate to call for help

Clinical Evaluation A B C D E
Immediately life-threatening problems are most commonly due to problems in the airway, breathing or
circulation. Therefore, in all critically ill patients, it is important to assess these first.

Take action when a problem is found before going to the next step of the assessment

In children
All the paediatric sections must be read together with the rest of the chapter. Issues that affect adults as well
as children are not mentioned a second time in the children’s section – rather, this section is used to discuss
the ways the signs/symptoms, treatments, etc, may be different in infants and children than in adults.

How do children differ from adults?

 Children are more able to compensate1 for illness so signs of illness may not be obvious until the child is
very severely ill.
 When children do deteriorate, it happens very quickly.
 Signs of deterioration are often non-specific, such as lethargy (drowsy and lacking in energy) or non-stop
crying
 Early treatment has a greater effect.
 Technical procedures are harder and take more time.

A = Airway
Airway emergencies require an urgent response, as patients may get worse very rapidly. It is therefore
essential not only to train to manage these situations but to be properly prepared. When starting work in an
unfamiliar environment always check availability and proper functioning of emergency airway management
equipment, including location and contents of the emergency trolley and the intubation “kit”.

1 Compensation: the way the body adjusts itself in order to correct any abnormalities in structure or function

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BASIC DHS for Nurses

Objectives of emergency airway management

 Make sure the airway is patent2
 Make sure there is ventilation (movement of air in and out) of the lungs
 Protect the lungs from soiling (dirtying, contamination by secretions or other fluids)

If the patient is conscious, ask him a simple question. If he can answer, the airway is patent.

If the patient is unconscious, the first step is to look, listen and feel for breathing (Figure 1).

Figure 1

Look to see if the chest is moving. However, just because the chest is moving and the patient is trying to
breathe, it does not mean he is moving any air in and out of his lungs. Therefore, it is also important to:
• Listen for breath sounds and
• Feel for air moving in and out
Upper airway obstruction (blockage)
 Obstruction is diagnosed on the basis of clinical symptoms and signs. These may be mild to begin with
and include changes to the voice, hoarseness and coughing, sometimes progressing to inspiratory stridor
(a high pitched wheezing sound), crowing or noisy breathing, choking and drooling (saliva coming out of
the mouth because unable to swallow)..
 Shortness of breath, weak cough, respiratory distress and signs of a desaturating patient, such as anxiety,
confusion, exhaustion and cyanosis3 may be present as the obstruction worsens.
 Observing speed of onset and progression is important in deciding the need for urgent treatment.
 In unconscious patients, listen and feel whether gas is moving through the mouth or nose.

Remember that chest movement can occur, even if the airway is completely obstructed .

Signs of airway obstruction can include

 See-saw movements of the chest and abdomen (Figure 2), (chest and abdomen move in opposite
directions)

2Patent = open, not blocked/obstructed.

3Cyanosis = bluish colour of lips, lining of mouth and nail beds. May be difficult to detect in dark skinned
patients

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 Emergency assessment

Figure 2. See-saw movements of the chest and abdomen (where the chest and abdomen move in opposite directions) may be a sign of
airway obstruction

 Intercostal and subcostal recession (the muscles are sucked inwards) (Figure 3)
 Use of accessory muscles for respiration (Figure 3)
 Gurgling noises or stridor
 Note that stridor may be absent in severe cases (obstruction is so severe that very minimal air moves in
and out, so no sound)

Figure 3. Signs of respiratory distress include use of accessory muscles, flaring of nostrils and recession (in-sucking during inspiration)

Don’t forget to open the mouth to check if an object or excess secretions are blocking the airway. If this is the
case, use mechanical suction to clear airways.

If an open airway and breathing cannot be restored quickly and easily, call for help early. In most cases
simple measures will be enough to allow time for more advanced procedures.

For all patients, manage the airways with basic airway techniques and give oxygen (≥ 5L)

In children
Desaturation is the number 1 cause of cardio-respiratory arrest.
The airways in children are small, may obstruct very easily and may get worse very quickly. Therefore worry
about the child with signs of airway obstruction (e.g. stridor).

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BASIC DHS for Nurses

A history of playing with small objects before the symptoms start is important information and may give the
reason for the airway obstruction

Signs of upper airway obstruction

 Hoarse or quiet voice
 Brassy or barking cough
 Abnormal inspiratory noises (stridor and/or wheeze)
 Clinical signs that breathing is becoming more difficult (chest wall recession (in sucking), nasal flaring
(enlarged nostrils), increased respiratory rate, use of accessory muscles of respiration).
 A child with breathing dificulties will usually not want to lie down and insist or fight to sit up (infants who
cannot yet sit may adopt a position with marked neck extension. Allow the child to stay in the position he
chooses and use basic airway techniques
One main cause for airway obstruction is blockage by the tongue and soft tissues in the mouth and pharynx.
There are several methods that can be used to lift the tongue and pharyngeal tissues anteriorly (forwards) to
open the airway. You should be familiar with and be able to perform all these techniques.

 The head tilt is easy and effective. A hand firmly placed on the forehead tilts the head backward (figure 4).
 Placing the fingers of the other hand under the bony part of the lower jaw and lifting the chin forward
complete the head tilt-chin lift.
 The triple airway manoeuvre is used when other methods have failed to open the airway.
 It combines a head-tilt chin-lift with a jaw thrust. The head is tilted back in extension and the fingers of
both hands grasp the ramus of the mandible, which is pressed forward and upward. Both thumbs are then
used to open the lower lips (Figure 4).

NEVER perform any airway manoeuvre that involves a head-tilt for any trauma patient with
possible cervical spine instability.

Figure 4 Head-tilt chin-lift (left) and triple manoeuvre (right)

 The modified jaw thrust leaves out the head tilt and is useful if the cervical spine is unstable (Figure 5).
Keep the head and neck in alignment (in a straight line) while pressing the mandible forward and upward.

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 Emergency assessment

Figure 5. Modified jaw thrust

In children

Figure 6. Positioning to open airway in infants and young children. The neck should be slightly extended, as shown. A small roll under the
shoulders may be used to help correct airway positioning in smaller children but is not definitely needed.

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BASIC DHS for Nurses

Airway suction
Suction may be helpful in removing secretions or small objects from the upper airway. This should be done
carefully in conscious patients, as it may cause vomiting.
In children, it may lead to spasm of the larynx or apnoea (no breathing effort).

Oro/naso-pharyngeal airways
Placement of an oropharyngeal airway or nasopharyngeal airway may be useful to prevent soft tissues from
blocking the airway in patients with decreased consciousness at the levels of the soft palate, epiglottis and
base of tongue. Do NOT use these airways in patients who are fully conscious.

A nasopharyngeal airway is a soft rubber or plastic tube inserted into the nostril and pushed backwards along
the floor of the nose into the posterior pharynx. It is useful for the patient who is still semiconscious, because it
has less risk of inducing gagging and vomiting. It should not be used in patients with head or face trauma.

Figure 7. Nasopharyngeal airway

The correct size of nasopharyngeal airways should be chosen by holding it up to the patient’s jaw. The tube
should reach from the patient’s nostril to their lower ear. To put in, use lubricant and insert with the bevel
opening facing toward the nose.
An oropharyngeal airway (Guedel airway) provides an open airway for spontaneous or bag-mask ventilation
when proper head and jaw positioning is not enough. It is inserted with the outer curve facing the palate and
then rotated 180° into the proper position as it is moved forwards. (Figure 8. It should not be used in
conscious patients.

Figure 8 Insertion of oropharyngeal airway

It is important to choose the right size (figure 9). Too big or small an airway may worsen obstruction or be
ineffective. To decide which size to use: place the airway with its flange (flat disk area) at the centre of the
incisors, and the airway should reach the angle of the mandible.

Complications include mucosal trauma, epistaxis (nose-bleed), aspiration (breathing in stomach contents into
the lungs).

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 Emergency assessment

Oral (Guedel) airways should only be used on patients who are unconscious. In the patient who is drowsy but
conscious, the hard plastic of an oral airway in the back of the throat is more likely to trigger a gag reflex,
possibly causing vomiting and/or aspiration.

In children
The Guedel (oropharyngeal) airway may be inserted following the curve of the palate or using the same
method as in adults. The most important thing is to use the least traumatic and most effective method in your
particular patient.
There are a large selection of paediatric sized Guedel airways suitable for all ages from neonates up to
adolescents. Size can be estimated (guessed) (see below). However the “ideal” size is the one that improves
airway patency without causing complications. Sometimes a Guedel airway cannot improve the airway
because other factors are involved.

Figure 9 Correct airway selection: Place the oropharyngeal airway at the corner of the mouth. The tip should just reach the angle of
mandible. Too large an airway will cause airway obstruction and possibly laryngospasm. If the airway is too small, the tongue will block
the end.

B = Breathing
Look for:
 Adequate respiratory rate - number of breaths in one minute, measured by observing the rise and fall of
the chest as air moves in and out. (1 full breath = inhale and exhale)

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BASIC DHS for Nurses

 Norm for adults:

< 10/min: bradypnea => patient needs are not covered
> 20/min: tachypnea => this is often too fast to have proper gas exchange

Get help if the respiratory rate is <8/min or >30/min.

A high respiratory rate is always worrying

A low rate may be the final stage of severe illness and may be a sign that the patient will soon die, or it may
be because the respiratory centre is failing.
 Signs of severe breathing difficulties: Flaring (enlargement) of the nostrils, use of accessory muscles,
recession and inability to complete a sentence in one breath (Figure 2).

An increase in the respiratory rate (RR) can be normal when the body has sensed a need
to increase the ventilation, but you need to know why. Talk to the patient and calm him if
you can

 Central cyanosis - a bluish color of the skin or mucous membranes in the center of the body, such as the
mouth, lips, nose. This is a sign that the blood is not receiving oxygen, and that this blood without oxygen
is circulating in the entire system. It can be hard to detect, especially in dark-skinned or anaemic patients.
 Abnormal movement of the chest wall (see airway assessment above), chest trauma
 Pulse oximetery is an extremely useful bedside investigation tool. However, it is not good for detecting
abnormal signs in ventilation (the process of moving gas in and out of the lungs).

In children
 Tachypnoea (fast breathing) is an important sign (no matter what is the cause); a low respiratory rate or
apnoea are usually signs of extreme exhaustion.
 Respiratory rates are higher in infancy but can also vary depending on activity (Table 1).
 Look specifically for nasal flaring, intercostal and subcostal recession (Figure 10) as signs of respiratory
distress.

Figure 10. Subcostal and intercostal recession

 Agitation for no obvious reason and altered consciousness in children with breathing difficulties are
worrying signs.
 Cyanosis is a late sign. It is difficult to detect in dark-skinned patients and if the patient is severely
anaemic.

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 Emergency assessment

C = Circulation
The main aim of blood circulation is to provide oxygen and glucose to the different organs. Level of
consciousness, skin/conjunctiva (membrane inside the eyelids) colour, temperature and pulse rate should be
quickly assessed, as they give a useful idea of the circulation.
A pink face and extremities (hands and feet) suggest the patient is not in shock, while a pale grey face and
pale or cold extremities suggest shock. Especially in the trauma patient, these signs could suggest
hemorrhagic shock, caused by blood loss (of at least 30%). When assessing circulation, look for any obvious
signs of uncontrolled bleeding.

Hypotension is a late sign of haemorrhagic shock

Low blood pressure

 Shock (not enough blood flow to organs) may happen without low blood pressure.
 Before a fall in blood pressure happens, the body may try to compensate for low blood flow by increasing
the heart rate (tachycardia)
 Some people have low blood pressure under normal circumstances. However, check carefully for signs of
shock in non-pregnant patients with systolic blood pressure < 90 mmHg (refer to Shock chapter). Even if a
patient's blood pressure is within the normal range, it may still be low compared to his/her usual blood
pressure.
 The following are signs of inadequate blood flow to different organs:
 Decreased consciousness
 Skin mottling (areas of different colour) (Figure 11) and peripheral cyanosis

Figure 11. Skin mottling: a sign of inadequate blood flow

 “Dusty” appearance of skin (in dark-skinned patients)

 Cold peripheries (hands and feet)
 Poor capillary refill (Figure 8) ≥3 sec
 Low urine output <0.5 ml/kg/h (<30 ml/h for a 60 kg patient)

Figure 12. Slow capillary refill (>3 seconds) indicates inadequate blood flow in children and younger adults. In elderly and cold
environment, patients capillary refill may take up to 4.5 seconds. Press for 2 seconds before releasing.

In children
 Hypotension is a late sign of cardiovascular problems. Signs of inadequate blood flow to tissues (cold
peripheries, capillary refill >3 seconds), altered consciousness or oliguria (reduced urine output) indicate a
severe illness, even in a child with a normal blood pressure.
 Tachycardia is generally a response to a decreased cardiac output (from any cause). Infants under 3

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BASIC DHS for Nurses

months with low cardiac output tend to develop marked tachycardia very early on because they have
limited ability to increase stroke volume.
After one year of age, a systolic blood pressure that is below 70+ (2 x age in years) mmHg is probably
abnormal (Table 1 at the end of this chapter gives more detailed information).

D = Disability

All unconscious patients have a high risk of aspiration. The patient should be placed in the
recovery position unless there is a chance that the patient has an injury to the spine.

 Decreased consciousness or confusion may be a sign of neurological disease, but may also be a sign of
severe systemic disease (e.g. desaturation, severe sepsis, shock).
 It has to be detected as soon as possible (observation, question)
 In all cases, if there is any head or spinal trauma, a neurological complication has to be considered.
 The AVPU system (Figure 13) is useful to quickly assess conscious level. However, the Glasgow Coma
Score (see Neurological emergencies chapter) is probably more useful for assessment of patients with
neurological disorders.

Figure 13. AVPU system for assessing consciousness. Patients who do not respond to talking or shaking are comatose

ALWAYS check for low blood glucose in patients with a disturbed conscious state or
seizures.

In children
Lethargy, drowsiness, severe confusion or agitation are important signs of severe illness and must not be
ignored. They indicate either severe illness or neurological disease.
Always think of hypoglycaemia (low blood sugar) in children with an abnormal mental state.
Seizures can be a sign of severe illness. But in children between 6 months and 5 years of age, seizures can
happen due to an acute rise in body temperature above 38°C (febrile convulsions). These do not necessarily
indicate serious illness. Serious causes of seizures and fever must, however, be ruled out in this group.

Recovery position
This position decreases the chance of upper airway obstruction or aspiration of gastric contents in a patient
with reduced consciousness. It should be used for patients with decreased consciousness, who do not have a
history of trauma, when:

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 Emergency assessment

 Patient is expected to rapidly regain consciousness (e.g. after general anaesthesia or convulsion).
 When it is not possible to completely protect the airway (e.g. intubation and/or tracheostomy is not
possible).

Placing the patient in the recovery position

 If the patient is wearing glasses remove them.
 Straighten the patient’s legs.
 Stand next to the patient’s bed, and then perform the following:

Move the arm nearest to you so Bring the far arm across the chest With your other hand grasp the
that the shoulder is abducted to and hold the back of the hand far leg just above the knee and
90° and externally rotated and the against the victim’s cheek nearest pull it up to flex the hip and knee.
elbow flexed, with the palm to you Keep the foot on the bed
upwards

Pull on the leg to roll the patient Adjust the leg so that the hip and Tilt the head back to make sure
towards you while keeping the knee are flexed to 90° the airway remains open,
hand pressed against the cheek adjusting the hand under the
cheek to keep the head tilted.
Check breathing regularly
Figure 14 Recovery position

In children
The smaller body size and weight of paediatric patients makes it easy to put them into the recovery position,
but stabilisation of their head and cervical spine must be ensured (as for adults) while turning them and
afterwards.
Infants and toddlers with relatively short limbs tend to roll backwards or forwards away from the recovery
position. The support of a small pillow or a rolled-up blanket placed behind their back may be useful to keep
them in the correct position. There should be no pressure on the chest or abdomen that may make breathing
more difficult.

E = Exposure and Environment

The patient should be completely undressed. This allows unrestricted access to the patient in case of
emergencies or procedures, and it allows for a full inspection and examination of the patient (discussed next).

It is essential to cover the patient with warm blankets to prevent hypothermia (low body temperature) in the
emergency department. Intravenous fluids should be warmed and a warm environment maintained. Patient
privacy should be preserved.

In children

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BASIC DHS for Nurses

Infants and children get cold quickly when exposed for examination or procedures.

Component Assessment
Airway Assess airway patency
Looking for:
Abnormal chest movement may indicate airway obstruction

Listening for:
Snoring (indicates tongue or soft tissue obstruction)
Stridor (indicates obstruction at or above the vocal cords)
Wheezing (indicates obstruction below the vocal cords)
Gurgling (indicates fluid in the airway)
Hoarse voice (indicates oedema of the vocal cords) or
Silence (indicates complete obstruction)
Breathing Assess rate and depth of breathing and SpO2
Look for:
Signs of respiratory distress
Increased respiratory rate
Shallow breathing
Use of accessory muscles
Nasal flaring
See-saw breathing
Forward posture
Respiratory depression
Decreased respiratory rate
Shallow breathing

Circulation Heart rate, heart rhythm and blood pressure

Sweating
Assess skin colour

Disability Assess level of consciousness using the GCS or AVPU scale.

Generally a GCS <9 indicates that intubation should be considered
Table 1. Assessing the patient’s vital signs

Secondary survey
This should be carried out after initial resuscitation and treatment of immediately life-threatening injuries.

Obtain a quick focused history using AMPLE:

 Allergies
 Medications
 Past medical history/pregnancy
 Last meal
 Events/environment leading to injury and illness

Ask if the patient has had any contact with traditional medicine

Examination
This involves a thorough head-to-toe examination, which should include examination of the scalp, eyes,
maxillofacial region, spine, neck, and perineum, as well as more obvious areas, such as neurological system,
cardiovascular system, chest, abdomen, pelvis and limbs. Penetrating trauma (trauma resulting from
something entering the body) entrance and exit wounds should be looked for. Assess for any signs of internal
and external bleeding.

A log roll is carried out in order to examine the patient’s back (including head and neck) and to perform a
rectal examination whilst minimising movement of the spine (Figure 15).

This action requires a minimum of 4 people: one at the head to stabilise (keep still) the neck and coordinate
the timing of the roll; two at one side of the patient, who roll the patient 90-degrees towards them and support

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 Emergency assessment

him in that position; and a fourth person on the patient’s other side to examine the patient’s back (including
head and neck) and perform a rectal examination.

Patients should also be log rolled for transfer (e.g. to stretcher) and to apply a pelvic binder. All major trauma
patients should be moved in this way until spinal injury is excluded.

Figure 12. Log rolling a patient. The fourth person (not shown) examines the back. Note the position of the hands of the person who is
stabilizing the neck. His forearms should be pressed against the patient’s head to stop it moving sideways.

Pain management
Management of pain from life-threatening causes is essential. If the patient is conscious but not able to talk,
sweating, agitated, and unable to find any comfortable position, that could mean there are internal injuries.
 Severe abdominal pain => internal bleeding, intestinal perforation (hole or break), spleen fracture
 Chest pain => myocardial infarction (MI), cardiac tamponade
 Headache => meningitis, cerebral oedema or haematoma (collection of blood)
Listen carefully to the patient’s complaints, which can give you lots of information about the patient’s condition.
Pain will increase the patient’s energy needs and this can worsen life-threatening injuries (refer to Pain
management chapter)

Triage
Triage is the process of prioritizing (putting them in order of importance) patients depending on how severe
their illness is. In general the sickest patients should be seen first as this will increase the survival rate and
save lives. Patients with ABCD problems will need to be seen immediately. The triage nurse is the first person
who receives the patient and can identify if the patient’s condition could be life threatening.
There are many tools to help triage (appendix 1).
The nurse must make sure the patient is safe and comfortable: place in a patient bed/area, ensure privacy,
protect from falling, closely monitor.
Identify the main complaint; take the history from the patient or the attendant (medical, trauma) at the same
time as performing the assessment.
Use infection control precautions during triage, initial assessment and emergency treatments

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BASIC DHS for Nurses

Warning signs of severe illness

Sign Danger Abnormal Normal Abnormal Danger

Airway Gurgling, Normal

sounds snoring
(in patient with
↓
consciousness
Stridor

Central Present Absent

cyanosis

Breathing <8/min 8-10/min 11-20/min 21-30/min >30/min

rate

Breathing Gasping Use of Recession,

pattern accessory nasal flaring,
muscles see-saw
pattern

Speech Unable to Talks freely

complete
sentence in
one breath

Oxygen <90% 90-94% 95-98% SpO2 above

saturation 98% can be
normal

Heart rate <45/min 45-59/min 60-100/min 101-130/min >130/min

Pulse No radial pulse Weak pulse

volume

Systolic <80 mmHg or 80-90 mmHg 90-140 140-180 >180 mmHg

blood 30% less than or 25% lower mmHg mmHg
pressure patient’s than patient’s
normal SBP normal SBP

Capillary >5s 3-5s ≤2s

refill time

Conscious Responds to Confused Alert or Agitated

level pain or responds to
unconscious voice

Tempera- <35ºC 35-35.9ºC 36-37.4ºC 37.5-39.5ºC >39.5ºC

ture

Urine <0.5 ml/kg/h <0.5 ml/kg/h 0.5-2 ml/kg/h >2 ml/kg/h

output for 12 hours for 6 hours

Gastro- None Coffee ground Vomiting

intestinal vomit in blood,
bleeding nasogastric melaena
tube

Sodium <120 mmol/l >150 mmol/l

Potassium <2.5 mmol/l >6 mmol/l

Glucose < 55 mg/dl (3 < 70 mg/dl 20 mg/dl > 300 mg/dl

mmol/l) (3.9 mmol/l) (6.6 mmol/l) (16.6 mol/l)

Table 2. Warning signs in adults

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 Emergency assessment

Warning signs in children

1. Airway threat
2. Hypoxaemia SpO2

<90% in any amount of oxygen

3. Severe respiratory distress, apnoea or cyanosis

4. Tachypnoea

Age Respiratory rate/min

Term-3 months >60

4-12 months >50

1-4 years >40

5-12 years >30

12 years + >25

5. Bradycardia or Tachycardia
Age Bradycardia (beats/min) Tachycardia (beats/min)

Term-3 months <100 >180

4-12 months <100 >180
1-4 years <90 >160
5-12 years <80 >140
12 years + <60 >130

6. Hypotension
Age BP (systolic mmHg)

Term-3 months <50

4-12 months <60
1-4 years <70
5-12 years <80
12 years + <90

7. Acute change in neurological status or convulsion

8. Cardiac or respiratory arrest

9. Other features suggestive of severe illness

Hypo or hyperkalemia Hypo or hypernatremia

Low serum bicarbonate Severe Anaemia
Easy bruising, purpura Hematemesis or melena
Jaundice Urine output < 1 ml/kg/hr
Table 3. Clinical warning signs in children

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 Acute Respiratory Failure

Acute respiratory failure

Understanding the changes in the body that happen as a result of disease makes it easier to think
about respiratory failure in a logical way. It also helps to work out appropriate management strategies.

The respiratory system is designed to transfer oxygen from air into the blood, where it can be taken to
the tissues. During this process, CO2 is eliminated.
This system involves pulmonary ventilation (breathing), gas exchange, and perfusion (flow of blood) of
the lungs. Oxygen is transferred into the lungs by ventilation, and enters the blood by passing across
the alveolar membrane. An effective circulation is needed to deliver oxygenated blood to the cells and
return CO2 to the lungs for elimination.

Anatomy

Nasal cavity

Pharynx
Upper respiratory tract

Larynx
Lower respiratory tract

Trachea

Intercostal Bronchus
muscles

Pleura

Diaphragm

Figure 1 Anatomy of respiratory system

The respiratory system is made up of the following parts, divided into the upper and lower respiratory
tracts, and chest wall:

Upper Respiratory Tract

 Mouth, nose & nasal cavity: Warm, filter and moisten the incoming air
 Pharynx: Here the throat divides into the trachea (wind pipe) and oesophagus (food pipe).
 Larynx: This is also called the voice box as it is where sound is made. It helps protect the trachea
by producing a strong cough reflex if any solid objects pass the epiglottis.

Lower Respiratory Tract

 Trachea: Carries air from the larynx into the lungs.
 Bronchi: The trachea divides into two bronchi, one entering the left and one entering the right
lung. Once inside the lung the bronchi split several ways, forming tertiary bronchi.
 Bronchioles: Tertiary bronchi continue to divide and become bronchioles. They lead to alveolar
sacs.
 Alveoli: Thin-walled sacs, allowing exchange of gas (oxygen and carbon dioxide).
 A network of capillaries, into which the inspired gases pass

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BASIC DHS for Nurses

Thoracic wall
 12 pairs of ribs, separated by intercostal muscles
 Pleura: Each lung is covered by a pleural sac, which is made up of two layers of pleura (visceral
and parietal pleura)
 Diaphragm: a wide muscle, between thoracic and abdominal cavities

In children
There are anatomical and physiological differences between adults and children in all these parts. This
is why children are more likely to develop respiratory failure.

Airway
 Small infants less than 6 months have narrow nasal passages and prefer to breathe through the
nose than the mouth. Nasal obstruction (e.g. secretions, oedema) can lead to significant
respiratory distress, especially during feeding and sleeping.
 Younger children have a large tongue and their oropharynx is relatively small. In children over 2-3
years, adenoids and tonsils may be enlarged and this can lead to upper airway obstruction.

Pulmonary ventilation
Movement of air in and out of the lungs. It is caused by the pressure difference between the air
(atmosphere) and the lungs, and divided into 2 movements: inspiration and expiration.

Respiratory movements
Inspiration (breathing in)
Contraction of inspiratory muscles and the diaphragm causes an outward and upward movement of
the chest wall and downward movement of the diaphragm which makes a negative pressure inside the
pleural cavity (figure 2)

Figure 2 Outward and upward movement of the chest wall and downward movement of the diaphragm which makes a negative
pressure inside the pleural cavity

Gas is then sucked in through the upper and lower airways into the alveoli of the lungs (figure 3).

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 Acute Respiratory Failure

Figure 3 Gas is sucked in through the upper and lower airways into the alveoli of the lungs

The diaphragm, and, to a lesser extent, the intercostal muscles are involved in quiet breathing. Other
“accessory” muscles of respiration and intercostal muscles are mostly only used during heavy
breathing (e.g. exercise) or when the patient has respiratory problems.
Expiration (breathing out)
Normally this is a passive movement (no effort involved). The respiratory muscles relax and the lungs
deflate which moves gas from the alveoli to the atmosphere.

Minute ventilation
The volume of gas breathed in and out during one normal breath is known as the tidal volume (VT).
The volume of gas breathed in and out during normal quiet breathing during 1 minute is known as the
minute volume or minute ventilation.

Minute ventilation = VT x Respiratory rate

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BASIC DHS for Nurses

Control of ventilation

Brainstem
Spinal cord Airway
Nerve root

Lung
Nerve

Pleura

Neuromuscular
junction
Chest wall
Respiratory
muscle

Figure 3 : Structures involved in ventilation

Ventilation is controlled by the respiratory center in the brainstem. This responds to changes in PaCO2
of the cerebrospinal fluid:
PaCO2 ⇒  respiratory rate
PaCO2 ⇒  respiratory rate
The respiratory centre isn’t stimulated by oxygen level, unless it is very very low.
When the respiratory centre is stimulated, a nerve impulse is sent to the inspiratory muscles via the
descending brainstem tracts, spinal cord, and nerves (figure 3). Disease at any of these sites may
cause decreased ventilation.

Gas exchange
This Is the transfer of oxygen and carbon dioxide across the alveolar capillary membrane (between
alveolar sac and blood).

Gas transfer across the membrane

Carbon dioxide passes from the blood into the alveoli because the level in the blood is higher than the
level in the alveoli (PACO2).
Oxygen passes in the opposite direction because the level in the alveoli (PAO2) is higher than in the
blood (figure 4). Once oxygen passes into the blood, it binds to haemoglobin.
Gas flow

Low CO2
CO 2
High

High O2
CO 2

O2

Low O2

Figure 4. Transfer of carbon dioxide and oxygen in a normal alveolus

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 Acute Respiratory Failure

A change of carbon dioxide or oxygen level in the alveolus will change the gradient (concentration
difference) between blood and alveolus and will change the concentration in the blood.
The major factor affecting PAO2 is the inspired oxygen concentration (in room air: oxygen
concentration = FiO2 = 21%). Increasing the oxygen flow rate increases the concentration that the
patient breathes, increases the alveolar pressure of oxygen and therefore aids the transfer of oxygen
from the alveoli to blood.
The major factor affecting PACO2 is the rate of removal, which is dependent on the minute ventilation
(Minute ventilation = (VT x Respiratory rate). Continual replacement of the alveolar gas with air (which
contains no carbon dioxide) keeps the alveolar CO2 concentration low.

Ventilation- perfusion matching

In order for oxygen to be transferred from the alveoli to the blood and carbon dioxide from blood into
the alveoli, the alveoli must be perfused (supplied with blood) by a capillary.
For the best possible gas exchange, each region of the lung should be equally ventilated and perfused
If the alveoli are perfused but not ventilated, no gas exchange occurs (Figure 5). This is known as
shunting. It is the most common cause of desaturation in critically ill patients.

Figure 5 : Alveolus perfused but not ventilated (shunt), as a result the blood is not oxygenated

Transport of oxygen to tissues

Most oxygen is carried around the body attached to haemoglobin. This binding takes place in the
lungs due to the high concentration of oxygen. Oxygen is released from haemoglobin in the tissues
and transferred from the blood into organs.

Supply of oxygen to tissues depends on Hb concentration, oxygen saturation and cardiac output.

In children
Exchange system
 Infants and young children have a relatively small area for gas exchange because alveoli and
distal bronchioles are not fully developed.
 Physiological shunting is higher in small children.
 In children up to 8 years of age, normal lung volumes are close to closing volume at the end of
expiration. Since closing volume is the lung volume at which terminal bronchioles start collapsing,
if the terminal bronchioles collapse, the alveoli beyond the point of collapse are not ventilated and
shunting occurs.

Mechanical pump
 The stiffness of the chest wall prevents the lungs from collapsing.
 In young children, the chest wall is less stiff. This means:
 Atelectasis (partial or complete collapse of the lung) is more likely.
 Chest wall recession (sucking in of the chest wall) is more common.
 It is easy to overinflate the lungs with manual ventilation.

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BASIC DHS for Nurses

 In small infants it is mainly the diaphragm that powers inspiration because the ribs are more
horizontal (than in adults) and the intercostal muscles are weak. Therefore diseases that affect
diaphragm function (lung hyperinflation, abdominal distension) can quickly cause severe
respiratory problems..
 Respiratory muscles may get tired quickly in children. The younger the child is, the more easily
tired the muscles are.

Overall effects of differences in respiratory system

 Increased risk of airway obstruction
 More work needed to breath
 Dependence on the diaphragm working properly
 Limited ability to compensate

Figure 6. Differences between children and adults

Pathology
Acute respiratory failure happens when the respiratory system is no longer able to meet the metabolic
needs of the body. The lungs have two major functions: oxygenation of blood and the elimination of
carbon dioxide (CO2).
Respiratory failure may be acute or chronic, depending on the length of respiratory failure and the type
of the compensation. Acute respiratory failure may occur in a person without underlying pulmonary
disease, or may be in addition to chronic respiratory failure.

For practical reasons clinical assessment of the patient with respiratory failure should start with an
assessment of airway patency, followed by an assessment to find out the severity, type and cause of
respiratory failure (in that order). If the patient has an airway problem or severe respiratory failure,
treatment should be started before continuing with the rest of the clinical assessment.
Finding out the amount of tissue hypoxia and assessing how the body is compensating (increased
respiratory effort) can help in assessing how serious the problem is.

Signs of respiratory distress.

 Clinical signs of tissue hypoxia: changed mental state (ranging from anxiety and agitation to coma
and seizures) and cyanosis.
 Desaturation SpO2 < 90%
 Increased respiratory effort result:
 Dyspnoea4, tachypnoea5 or bradypnoea6

4 Dyspnoea = difficulty breathing

5 Tachypnoea = fast breathing
6 Bradypnoea = slow breathing

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 Acute Respiratory Failure

 Use of accessory respiratory muscles

 Nasal flaring7
 Inability to speak complete sentences
 Intercostal/suprasternal/ supraclavicular retraction
 See-saw breathing.
 General signs:
 Sweating
 Tachycardia
 Hypertension (hypotension and bradycardia are late signs)
 Anxiety, agitation, general body weakness

In children
Children have lower respiratory reserves and higher oxygen consumption, and therefore deteriorate
more quickly, particularly younger children. Therefore resuscitation of children must be fast and
efficient.

Clinical assessment
This is the most important form of monitoring

Look for signs of obvious respiratory distress (Figure 7).

Flaring of nostrils

Use of accessory
muscles of respiration

Intercostal recession

Subcostal recession

Figure 1. Signs of respiratory distress

If these are present, get help immediately.

If the patient does not show signs of respiratory distress, work systematically, step by step, through
your assessment.

In children
Signs of upper airway obstruction
 Hoarse or muffled voice
 Brassy (loud metallic sounding) or barking cough (sounds like a seal, as in Croup)
 Abnormal inspiratory noises (stridor and/or wheeze)
 Clinical signs of increased effort of breathing (chest wall recession, nasal flaring, increased
respiratory rate, use of accessory muscles of respiration).
 Child with respiratory distress who insist on sitting rather than lying down

7 Nasal flaring = widening of the nostrils as the patient breaths

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Patient’s conscious status

 Awake or drowsy? Use AVPU to assess consciousness.
 A decrease in consciousness may be due to not enough oxygen getting to the brain or not
enough carbon dioxide being removed.
 A decrease in consciousness due to a primary neurological problem can also cause airway
obstruction and impaired ventilation and oxygenation.

Respiratory rate
Count the patient’s respiratory rate (1 breath = 1 inspiration + 1 expiration)
The bedside monitor does not do this reliably.
Tachypnoea (rate > 20 breaths per minute for adults) can mean that the patient has difficulty in
breathing, but could also be caused by severe illness affecting another system. The more the RR
increases, the more the patient is in distress and the more the situation is life-threatening.
When compensatory systems collapse, the RR decreases and may mean that the patient may soon
have a respiratory arrest.

Chest movement
Look for depth and symmetry (both sides moving equally and together), recession and use of
accessory muscles.
Decreased chest movement on one side suggests lung disease on that side (e.g. pneumothorax).

Breathing sounds and speech

 Quiet, noisy or gurgling sounds may be due to sputum or airway obstruction.
 Stridor (inspiratory) is a high-pitched, musical sound. It is usually due to upper airway obstruction
and is a sign of severe illness.
 Wheezing (expiratory) is a typical sign of an asthma attack, due to partial obstruction of the lower
airways
 Grunting: sign of severe respiratory distress and characteristic of infants with pneumonia or
pulmonary oedema
 Gasping: sign of severe hypoxia and may be pre-terminal
 Hoarseness may indicate vocal cord dysfunction or inhalation of smoke

In children
Sounds made during breathing relate to the amount of air that is being moved and how severe the
airway obstruction is. As the obstruction gets worse, the sounds may get louder at first, but as the
airflow decreases, the sounds may get softer.
Signs of increased effort of breathing may disappear as the patient becomes exhausted. Therefore, if
the breathing noise or the effort of breathing decreases, this does not mean that the obstruction has
decreased.
Non-respiratory signs of severe upper airway obstruction include: exhaustion, altered conscious state,
sweating, tachy- or bradycardia and poor peripheral tissue perfusion.
Upper (extrathoracic8) airway obstruction tends to cause stridor, which is worse in inspiration while
intrathoracic obstruction tends to cause wheeze, which is worse in expiration.

Pulse oximetry reading

Check the SpO2 number ( should be 96-100%) and that the heart rate measured by the monitor and
the actual heart rate are the same. If they are not the SpO2 may be inaccurate. If there is any doubt
give oxygen first and then check the reading.
An unrecordable SpO2 waveform may be due to
 Poor blood supply in the limbs (cold extremities)
 Severe anaemia
 False nails, nail polish or henna
 Probe not in the correct position
 Too much movement of the hands or feet
 Lighting around the monitor is too bright

8 Extrathoracic = outside the chest

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Note that desaturation is a late sign of respiratory failure and the aim is to detect deterioration before
the patient desaturates.

In children
Errors are common. Make sure that the saturation probe fits properly so that the infrared light actually
passes through the tissue, and that the sensor is not affected by light from the surroundings. Wrap-
around probes, if available, should be used in infants and small children for continuous monitoring.
Avoid putting them on too tightly: too much pressure is painful, carries a risk of pressure injury and
decreases perfusion and therefore the sensitivity of the device.

Skin colour/temperature
 Does the patient look pink and warm, or grey and moist from sweating?
 Look for central cyanosis (bluish colour of lips, inside mouth)

Haemodynamic status
Tachycardia and hypertension may be signs that the body is trying to make up for the desaturation.
Cyanosis, hypotension and bradycardia are signs that cardio- respiratory arrest will soon follow as
compensatory mechanisms are no longer effective.

Secretion, expectoration
 Observe the amount, colour and smell of the secretion that will help to decide on the diagnosis. It
can be useful to take a sample of the sputum for lab analysis.
 Greenish and smelly : pneumonia
 Blood : tuberculosis
 Pinkish frothy: pulmonary oedema
 Suction might be necessary to clear the airway if there are a lot of secretions.

Auscultation of chest
If you are familiar with listening to the chest, it can provide useful information but it is not essential.
 Is there any air entry?
 Is it equal on both sides?
 Are there any wheezes or crackles? Wheeze presents as a high-pitched, musical, expiratory
sound.

The assessment should be recorded in the patient’s chart

Management
Desaturation damages tissues and if uncorrected, rapidly fatal. Desaturation should be treated by
giving oxygen while the cause is found and specific treatment started.

Posture
In general, gas exchange is improved in the sitting position compared to the lying position. As a result,
simply sitting the patient up may result in a big improvement.

A patient in respiratory distress will choose the position that is most comfortable for
him to breath in. Allow him to sit in the position he chooses.

In children
Children often naturally find the best position for breathing.
Unless completely exhausted or too young to sit by themselves, children with respiratory distress
usually sit up and lean forward. Do not force them to change their position of comfort unless there is a
specific clinical reason.

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Oxygen supplementation
Oxygen should be started immediately for all severely ill patients who have signs of severe respiratory
distress or SpO2 < 90%. Most patients will improve on oxygen within a few minutes.
A number of different ways to give oxygen have been developed.

In children
Children have a lower inspiratory flow rate and therefore when given extra oxygen, the inspired
oxygen concentration will be higher than in adults. Do not worry about what concentration is being
delivered. Give the maximum possible flow rate at first, then reduce it to the lowest flow rate that
results in an oxygen saturation >90%.
Nasal cannula
For O2 rate between 0.5L to 3L
Higher flow rates can irritate and dry the nasal mucosa.
The nasal cannula is comfortable and well tolerated at low flows but is not suitable for patients with
severe respiratory distress

In children
 In small children, high concentrations of oxygen can be delivered via a nasal cannula. Humidified
oxygen should be used if oxygen therapy will be used for a long time.
 In infants the cannula can cause nasal obstruction.
 Babies under 6 month only breathe through the nose. Always clear the nose with normal saline
and soft suction.
Simple face-masks (Hudson masks)
For O2 rate between 3L/min to 8L/min
Low flow rate will increase the risk of the patient inhaling CO2 that stays inside the mask.
Reservoir face-masks
For O2 rate >6L/min
The reservoir face mask (Figure 2) consists of a mask with valves and a reservoir bag.
The reservoir bag is filled from the 100% oxygen supply source. The delivered oxygen flow rate is
adjusted so that the bag remains inflated throughout the respiratory cycle.
During inspiration, oxygen is inspired from both the oxygen source and the reservoir. The giving of
oxygen can therefore be maximized.
If the oxygen flow rate is under minimum 6L/min, the bag could be partly filled by CO2 expired by the
patient. Rebreathing his own CO2 could alter his conscious state and worsen the respiratory distress.
However, high concentration masks are a very useful tool for giving high levels of oxygen to critically ill
patients.

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 Acute Respiratory Failure

Figure 2. Reservoir face mask

In children
Reservoir facemasks are available in different sizes and will work best when the mask fits the child’s
face. If the mask is placed tightly on the patient’s face, this will increase the delivered O2 but it may
cause more distress and increase the work needed to breathe.

Bag valve resuscitator (eg Ambu Bag)

The resuscitation bag will be used for pre-oxygenation before intubation or with patients who are not
able to maintain efficient ventilation. However it can also be used to provide a higher concentration of
oxygen than a reservoir facemask to patients who are still breathing adequately, provided the mask is
held tight to the face.
Adding a reservoir bag increases the ability of the system to provide 100% oxygen.

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BASIC DHS for Nurses

Figure 3. Self-inflating bag valve resuscitator

The mask size is extremely important in creating a good seal and aids effective ventilation.
Inform the patient to try to reduce their anxiety
It is important to check that bag mask ventilation is effective. Look to see if the chest is rising and
falling with bagging. The aim is to achieve normal chest expansion with each breath. Monitor the
patient with a pulse oximeter whenever possible.
Newer bags are equipped with a pressure valve that protects the lungs from barotrauma (damage to
the lungs due to pressure changes/overstretching).

Always use a transparent mask so that vomiting, condensation and the colour of
the lips can be easily seen

In children
Bag valve resuscitators should not be used to provide high- flow oxygen to infants who are able to
breathe on their own (< 1 year old). Children in this age group do not have enough respiratory muscle
power to open the valve without assistance from manual compression of the bag.
Equipment
After using the bag mask, the sterilisation technicians should disinfect the equipment. When the
device is returned to the unit, make sure the bag mask and all the valves have been well put together.
This can be checked by inflating the bag against your hand to feel the air flow. Make sure you use a
filter between the mask and the bag to avoid blood, sputum or vomit entering the bag. The filter should
only be used once and discarded after use.
How to ventilate with a self-inflating bag valve resuscitator
Choose the right size of mask and position you hand to make a seal (no gas can escape). Maintain an
open airway with one hand, place the mask over the patient’s mouth and nose with your other hand,

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 Acute Respiratory Failure

use the thumb and index finger of your first hand (making a C shape) to balance the mask on the
patient’s face then use your third, fourth and fifth fingers (E shape) to lift the jaw and face up to the
mask to create a seal. Once you have a seal, squeeze the bag to ventilate the lungs

Use the C-E technique (Figure 4)

Figure 7: C-E technique

Give regular breaths by gently squeezing the ambu-bag at a rate of 12 breath/min.

Do not completely deflate the bag when squeezing

Difficulties with bag mask ventilation can be expected in certain patients. These can be remembered
using the mnemonic: OBESE

O = Overweight (especially if the neck is large)

B = Bearded (difficult to get a seal)
E = Edentulous/Toothless (difficult to get a seal)
S = History of snoring or obstructive sleep apnoea
E = Elderly

Inadequate ventilation
Check that there is no visible object in the oropharynx before starting manual ventilation.
Check the patient is correctly positioned (using the triple manoeuvre to open the airway) and consider
using an oral or nasopharyngeal airway.
If ventilation is not effective (cannot produce adequate chest movement and/or SpO2 is <90%), re-
check the position and then, if necessary, use a two-person method (Figure 8). One person holds the
mask with two hands, the other squeezes the bag.

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BASIC DHS for Nurses

Figure 8. Two-person method for bag mask ventilation

Inflation of gas into the stomach can happen if the airway has not been properly
opened and if the bag is squeezed too much. It increases the risk of vomiting and
aspiration

In children
 Choose the correct size and shape of face mask to get a good seal against the face. The mask
should cover the mouth and nose without compressing either and without covering the eyes
(Figure 1). If the patient is between sizes, the larger size is usually better.

Figure 9. An appropriately sized mask should cover the mouth and nose without compressing either and without covering the
eyes

 Choose the correct resuscitator size according to weight:

 < 10 kg -- Neonate (volume 200-250 ml)
 10-30 kg -- Paediatric (volume 600-700 ml)
 > 30 kg – Adult (volume 1500-2000 ml)

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 Acute Respiratory Failure

 Maintain a good airway position with your other hand while manually assisting the child’s
ventilation. This improves the chance of successful ventilation and reduces the risk of inflation of
the stomach.
 Use a manual ventilation rate of
 30/minute before 1 year of age (1 ventilation every 2 seconds)
 20/minute between 1 and 12 years old (1 ventilation every 3 seconds)
 10/minute after 12 years (same as adult).
 Avoid all of the following:
 Putting pressure on the floor of mouth which may force the tongue upwards (Figure 10):
apply 3rd, 4th and 5th fingers along the bony mandible NOT into soft tissues.
 Hyperextending the neck.
 Applying pressure to eyes with your fingers, hand or mask
 Gastric inflation: Can develop rapidly in children due to small stomach volumes. Adequate
chest expansion without putting air into the stomach means the bag mask ventilation is
being done properly. Use low inflation pressures whenever possible. Chest movement that
is just visible is usually enough.
 Bag mask resuscitators should not be used to provide oxygen to children <1 year who are
able to breathe satisfactorily on their own, as they are unable to open the valve without the
help of manual bagging.
Correct Incorrect

Tongue pushed up, obstructing mouth

Figure 10. Incorrect positioning of 3rd and 4th fingers results in floor of mouth being pushed up, forcing the tongue upwards and
causing airway obstruction

Chest drain
The aim is to remove air or fluids from the pleural cavity by a closed drainage system.This restores a
normal negative pressure in the intrapleural space so that the lung tissue can expand.

Complications during insertion

 Pain
 Bleeding by damaging the intercostal arteries
 Gas embolism
 Organ puncturing (lungs, spleen, liver)
 Incorrect placement with or without medically acquired injuries
 Cardiac arrhythmias, bradycardia

Close monitoring of ECG and SpO2 is very important during the procedure

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BASIC DHS for Nurses

Monitoring the chest drain after insertion

 Chest X-ray after insertion as prescribed by the doctor
 Regular follow-up X-rays over the next few days as prescribed by the doctor.
 Ask the doctor to prescribe pain treatment according to MSF pain protocol. The re-expansion of
the lung can be very painful, especially when suction is used.
 Closely watch breathing, pulse, blood pressure and oxygen saturation of the patient.
 Check all connections of the drainage system regularly.
 Check the underwater seal drainage system and make sure the tubing lies below the fluid level

Figure 11. Three-bottle chest drain system. The first bottle is connected to the patient’s chest via the intercostal catheter. It is
used for collecting blood or pleural fluid. The second bottle creates the underwater seal, the level of the water is only that
required to maintain the seal in deep tidal breathing. The third bottle is used to control any applied suction using the level of
water to set the negative pressure (in this case -20 cm H2O) but the suction must only be turned so that bubbles are only just
occurring. If vigorous bubbling is created by dialing up a high suction with the suction device, the negative pressure in the
pleural space will be unpredictably higher than that which is set. If only air is being drained then a single bottle system with an
underwater seal is all that is required (figure 12). If draining fluid without suction then a two-bottle system, the first a trap and
the second the underwater seal is all that is required.

Swing
During inspiration, fluid in the drain moves up (more negative pressure is generated in the pleural
cavity), during expiration the fluid moves down. If no swing is present the tubing may be bent, there
may be a fluid filled loop or the lung may be fully re-expanded.

The chest drain collector should always be kept below the level of the patient. If you want to change
the side of the collector and pass it above the patient, clamp it during the move and unclamp when the
collector is below the patient’s level again.
Bubbling
 Presence of bubbling in the underwater seal chamber means that air is leaving the pleural cavity
through the tube to the water, which is good. Ask the patient to cough and observe:
 No bubbling indicates there is no air leaving.
 Bubbling on coughing indicates a small amount of air is leaving.
 Bubbling on expiration indicates a moderate amount of air is leaving. Bubbling throughout
inspiration and expiration indicates a large amount of air is leaving.
 Suction on the chest tube and re-expansion of the lung can cause the patient to cough and can be
very painful. Do regular pain assessments and ask the doctor to prescribe extra pain medication if
necessary.

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 Acute Respiratory Failure

Drainage
Record the amount of drained fluid in the patient’s records (fluid output) very closely during the first 8-
12 hours after insertion and at least once every 8 hours afterwards, more frequently if a lot of drainage
is observed. Large amounts of blood drainage over a short period of time (more than 100 ml/h) may
mean the patient is bleeding and should be reported to the doctor on duty. When drainage is lower
than 100 ml over 24 hours, the drain can usually be removed after medical order.
Observe the appearance of the liquid: colour, blood, pus; and record this in the patient’s file.

Suction
 The level of water in the suction chamber controls the amount of suction. When the suction device
is connected, this should result in gentle bubbling only (in the suction chamber).
 Vigorous bubbling means that excessive negative pressure may be being applied.
 No bubbling could indicate that the suction from the suction device is not enough and needs to
be increased or the pneumothorax (if this was the problem) is healed.
Check the level of the normal saline in the chest tube bottles regularly and make sure the tubing lies
well below the fluid level. The water level can decrease by evaporation and should be refilled if
necessary.
If a reusable glass bottle system is used, change the chest drain bottles every 72 hours.

Chest drain complications

 Subcutaneous (under the skin) emphysema – leakage of air into the subcutaneous space. A
crackling feeling can be felt when touching the patient’s skin
 In case of haemothorax, assess the need for transfusion once the chest drain is inserted (refer to
Blood transfusion chapter)
 Dress with an occlusive and sterile dressing to reduce the risk of site infection that can cause a
pleural infection.
 Encourage the patient to do hourly breathing exercises, 10 deep breaths per hour (refer to Chest
physiotherapy chapter)
 A tension pneumothorax can occur if:
 Accidental disconnection of the chest tube from the drainage system
 Incorrect installation of the 3 bottles system
 Clamping the chest drain. If you do clamp the drain, do it for as short a time as possible
(always ask the doctor on duty if there are any reasons this should not be done)

Pneumonia
An acute infection of the lungs often associated with fever, sweating and rigors. The chest X-ray and
findings on listening to the chest are helpful in making the diagnosis.

The most common respiratory signs are cough, sputum production, chest pain, shortness of breath
and desaturation.

Blood and sputum cultures should be carried out if available, before giving any antibiotics, but should
never delay the giving of them. X-ray can be done after the antibiotic treatment.

Management and Treatment

 Standard respiratory distress assessment, monitoring and management (refer to Clinical
assessment and Management principles chapter)
 High-flow oxygen adjusted to keep SpO2 > 90%
 Fluid to partially correct dehydration and provide maintenance requirements (prolonged fever can
dehydrate the patient)
 It is important to give appropriate antibiotics as quickly as possible (1h max)

In children
Dehydration can occur very quickly in any chidren with fever. Without any signs of respiratory distress,
breastfeeding has to be maintained.
If severe respiratory distress, NG tube and enteral feeding has to be considered.

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BASIC DHS for Nurses

Lung atelectasis (collapse)

Lying in bed for a long time in the same position can cause sections of alveoli (tiny air spaces) to
collapse, and air cannot enter. This is called atelectasis. These collapses in the tiny air spaces of the
lungs reduce gas exchange.

To prevent atelectasis and reopen any alveoli that have collapsed, the following can be done:
 If the patient is conscious and can follow commands, instruct them to cough regularly and take
deep breaths.
 Instruct or help the patient to change position regularly in bed, and help them to sit up often, in a
chair or in the bed with pillows.
 If available, ask the patient to use a plastic container filled with water, and a straw or plastic
cannula, and to blow bubbles in the water through the straw or cannula. This helps exercise the
lungs. Put more water in as the patient progresses to increase the difficulty.
 Monitor and treat the patient’s pain effectively. Pain prevents them from breathing properly. .

Acute Cardiogenic Pulmonary Oedema

Acute cardiogenic pulmonary oedema is the abnormal collecting of fluid in the lungs, which makes it
difficult for oxygen from the air to pass into the blood. Generally caused by heart failure

The symptoms to look for are similar to any respiratory distress with cough and characteristic pink
frothy sputum.

The patient talks about a sensation of drowning and gets more breathless lying
down

Causes
 Severe hypertension
 Coronary artery disease
 Acute decompensated heart failure (ADHF)
 Heart valve problems
 Fluid overload

Management and treatment

This is a life threatening medical emergency. The first part of the management is based on treatment
of the symptoms to save the patient’s life and the cause is treated afterwards.
 Usual respiratory distress assessment, monitoring and management (refer to Clinical assessment
and Management principles chapter)
 Nothing to eat or drink
 High-flow oxygen adjusted to keep SpO2 > 90%
 IV line, give only enough fluid (5% glucose) to keep the line open
 Immediate IV diuretic (furosemide)
 IV vasodilator therapy (Isosorbide, Nicardipine, Hydralazine) optimizes cardiac output and helps to
move fluids from the lungs to the kidneys for excretion. Vasodilators should not be given to
hypotensive patients.
 Measuring urine output (a urinary catheter should be inserted) and observing the patient’s
respiratory state are the best ways to monitor the effectiveness of the treatment.
 Furosemide decreases blood potassium level and could cause cardiac arrythmias (refer to
Metabolic and electrolyte disturbances chapter)
 Non invasive ventilation (NIV) is a very efficient procedure for pulmonary oedema if available and
indicated (refer to Mechanical ventilation chapter)
 If the patient is severely hypotensive, cardiogenic shock management (refer to Cardiology
chapter) with catecholamine (eg Dopamine or epinephrine in a syringe pump) may be needed.

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 Acute Respiratory Failure

In cardiac patients, blood or fluid should be given at a slow rate. Close monitoring
for signs of overload is essential »

Pulmonary Embolism
Pulmonary embolism causes blockage in a pulmonary artery, usually caused by a deep vein
thrombosis (DVT) that breaks off and moves to the lungs. A small number of cases are caused by the
embolization of air or fat.

Pulmonary
embolus

Figure 13.. Pulmonary embolus

The symptoms include respiratory distress, usually sudden in onset, with normal breath sounds, dry
cough, shortness of breath, chest pain and haemoptysis9.
Look for signs of DVT (refer to Post surgery complications chapter).

Management and treatment

Like acute pulmonary oedema, pulmonary embolism is a medical emergency. The management is first
symptomatic treatment to save the patient’s life and second treatment of the cause.
 Standard respiratory distress assessment, monitoring and management (refer to Clinical
assessment and Management principles chapter)
 Let the patient lie down and do not move him
 High-flow oxygen adjusted to keep SpO2 > 90%
 Anticoagulation therapy according to medical prescription (IV heparin or SC low molecular weight
heparin).
Complications and monitoring of anticoagulation therapy
If the dose of anticoagulant therapy is too high the biggest risk is bleeding. The most common signs
are: nose bleed, bleeding gums, haematuria10, melaena11, bleeding at the puncture sites, spontaneous
haematoma and anaemia. If any of these signs appear, stop the treatment and call the doctor.

9 Haemoptysis = coughing up of blood from the lungs

10 Haematuria = blood in urine
11 Melaena = black, foul-smelling faeces, due to partially digested blood

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BASIC DHS for Nurses

Severe asthma
Asthma is a disease where airflow is obstructed, caused by irritation and inflammation of the
bronchioles. Severe asthmatic attacks are characterised by one or more of the following:
 Signs of respiratory distress (dyspnoea, tachypnoea), use of accessory respiratory muscles,
desaturation with SpO2 < 92% on air
 Unable to speak a sentence in one breath
 Extensive wheezing or silent chest
 Agitated, drowsy or exhausted
 Peak flow rate < 33% of normal or patient’s normal

Measuring peak flow

Zero the peak flow meter.
Ask the patient to take 3 deep breaths to make sure they completely fill their lungs.
Ask the patient to take a deep breath and blow as fast and hard as possible (figure 14). Measure the
peak flow three times, record the highest result in the patient’s file and inform the doctor.

Figure 14 Measuring peak flow

Age Male Female

15 years 540-600 410-445
35 years 590-665 425-465
65 years 510-550 360-375
Table 1. Normal range of peak expiratory flow rates (L/min) in adults. Peak expiratory flow rises until about 30-35 years, and
then falls again. In adults, height does not make a significant difference. Ranges given are for adults of 160-190 cm (males) and
152-183 cm (females)

How quickly the symptoms progress is important. Deterioration can be fast and patients with sudden
onset asthma may progress to respiratory arrest within one to six hours of the start of symptoms.
Close monitoring and repeated assessment of the patient’s condition is essential
Short term hypertension is a normal reaction during an asthma attack and doesn’t need to be treated

Management in order of importance

 Treatment of desaturation. Desaturation associated with asthma is usually mild to moderate and
responds to oxygen therapy by mask.
 Sitting posture
 Assessment and re-assessment of severity
 Nebulised or inhaled bronchodilators (Salbutamol and Ipratropium). Use oxygen for the
nebulisation if the patient desaturates. The rest of the treatment is aimed at reducing bronchial
inflammation (Prednisolone, Hydrocortisone IV).
 Removal or treatment of the cause of the acute deterioration. Most attacks of acute asthma are
caused by viral infection, but may be caused by bacterial infection. Known allergens12 should be
removed from the patient’s environment. A detailed history may reveal an allergic cause, aspirin or
non-steroidal sensitivity.

12 Allergens = substances that cause an allergic reaction

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 Acute Respiratory Failure

 The following clinical signs (see above) should be recorded regularly (e.g. every 30-60 minutes) or
before and after each dose of bronchodilator. Improvement or deterioration should be observed.
 Stay near the patient. Try to calm him as the feeling of suffocating is very scary for the patient, and
rapid breathing due to anxiety can worsen respiratory failure.

Figure 15. Allow the patient to sit up

The continuation of desaturation even when oxygen is given, arrhythmias, or any progressively
worsening symptoms described in Table 3, are indications for urgent referral to intensive care.
Even a slow progressive deterioration, despite nursing and medical treatment, suggests that rapid
reversal of the symptoms is unlikely.

Exhaustion, poor respiratory effort, silent chest, hypotension or depressed

conscious level indicate a deterioration to life-threatening asthma.

Inhalation therapy and Nebulization

With this therapy a drug is given directly into the lungs to treat airway diseases. It’s a quick and
efficient technique that has few side effects on the whole body. Lower doses are needed in inhalation
therapy compared to oral medications to get the same results. However, it does need the help of the
patient (for children in particular) and therefore you cannot be certain of the exact dose they have
received.
Metered-dose inhaler (MDI)
E.g. salbutamol and beclomethasone
A MDI is the first choice compared to nebulisation. The administration is easier and faster, the
treatment is as effective or even more effective and causes fewer adverse effects.
Good explanation to the patient is necessary.
Procedure
 The patient should sit up. Shake the MDI firmly and slightly bend the head backwards. If a new
MDI is used, discharge it twice in the air before giving it to the patient.
 Ask the patient to breathe out completely. The patient should not breathe out into the MDI or drug
particles may stick to the sides of the MDI.
 Ask the patient to slowly take a deep breath and press the inhaler down at the same time. He
should hold his breath for 5 to 10 seconds to allow the medication to pass deeply into the lungs
and then remove the MDI from his mouth.
 If several puffs need to be taken, repeat the steps above and wait one minute in between two
puffs to allow the respiratory system to open.
 If the patient needs to take two puffs of different medications, start with the bronchodilator
(Salubutamol, Ipratropium), wait 5 to 10 minutes to get the maximum effect, and only then give the
second medication. The respiratory tract will now be open and the particles of the second
medication will easily reach the deep airways.

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BASIC DHS for Nurses

 The MDI should not be cleaned with water. The mouthpiece can be cleaned with a damp cloth but
should be completely dry before use to avoid drug particles sticking to the wall of the mouthpiece.
 The dose of bronchodilator that reaches the airways can be increased by using a spacer or
chamber.

In children
In children <6 years old, the MDI should always be used with a spacer or chamber.
A plastic chamber (or spacer) can be used without a face mask for children under 4-5 years old. The
chamber has the advantage that the medication can be inhaled in several breaths and with less effort.
The child can breathe in the medication over a period of 20 seconds. Also, more of the drug gets into
the respiratory system and less in the mouth, the throat and the vocal cords.

If you don’t have a normal inhalation chamber, you can use two plastic bottles:
 Cut the bottom third off 2 different bottles and place the 2 open ends together, tucking one inside
the other.
 Put the inhalator in one of the bottle necks
 The patient’s mouth should go over the bottle neck on the opposite side.
Plastic spacers have electrostatic charges inside the chamber that attract drug particles and
significantly reduce the amount of drug delivered to the lungs. The electrostatic charge inside the
plastic spacer can be reduced by washing the spacer in a dilute solution (1:5000 or three to four drops
in a gallon of water) of dishwashing detergent. Do not rinse before use. This treatment improves drug
delivery as much as four times.
Before the first use and after weekly cleaning, two puffs can be sprayed into the chamber to lower the
static electricity.
Nebulising
Nebulisation should only be used if the patient is unable to cooperate, has a neurological problem or is
severely breathless. During an asthma attack, nebulisation should only be used if the patient is in
need of oxygen. As mentioned above, the metered-dose inhaler should be the first choice. However,
in severe asthma attacks, when inhalation of oxygen is also required, nebulised salbutamol (with or
without Ipratropium) can be used. The solution is then turned into a mist that will be inhaled.
With nebulisation, drugs can be mixed and can be given with oxygen”
Which medication
Salbutamol, Ipratropium for broncho-dilatation (asthma attack…)
Normal saline (NaCl 0.9%) to reduce the stickiness of secretions. This helps the patient to cough up
sputum and prepares for respiratory physiotherapy.
Procedure
Inform the patient about the treatment:
 Painless
 Duration of treatment (10-15 minutes)
 Usefulness
 Keep regularly breathing through the mouth breathing during the treatment (not through the nose)
The nebulisation solution has to be prepared just before the nebulisation to prevent contamination and
change in concentration.
A mouthpiece or mask can be used. They should not be shared between patients.
Sit the patient up and ask him to blow his nose and to spit out any secretions before the treatment if
possible
Add normal saline (NaCl 0.9%) with the medication if necessary to make the solution approximately 4
ml
Oxygen or air flow has to create a white smoke (6-8 litres/minute). For COPD patients, only use
oxygen on medical prescription (in desaturated patient).
Never reuse the remaining solution of a previous nebulisation
Mouth piece or mask, and aerosol container should be cleaned with water and detergent every day.
In non life-threatening situations, avoid nebulisation close to meals as they can cause nausea and
vomiting
Monitoring and adverse effects during the procedure
Bronchial congestion can occur if the patient is unable to cough up sputum.

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 Acute Respiratory Failure

Close respiratory monitoring is needed (respiratory rate, SpO2, skin colour, breathing effort) to
observe effectiveness of treatment and to detect and treat any complications.
Nebulisation of salbutamol can cause tremors (mild shaking), headache, tachycardia, restlessness
and/or agitation.

Chest physiotherapy
The nurse plays an important role in the physiotherapy treatment in ICU. The physiotherapist (if
available in the hospital) will only treat the patient once or twice a day, so it is the nurse’s (or
sometimes the family’s as well) responsibility to remind and encourage the patient to do his
physiotherapy exercises several times a day. The nurse should also position the patient in the best
way to make sure he can breathe as easily as possible and to prevent complications.

Respiratory complications such as decreased ventilation; atelectasis and pneumonia are common in
patients who cannot get out of bed, following surgery and anaesthesia (especially abdominal and
thoracic operations),.Chest physiotherapy should be seen as a prevention method and not only a
treatment. It helps clear secretions, increases ventilation, helps with lung expansion and improves the
cardiovascular system.

There are different chest physiotherapy techniques that can be used, depending on the patient’s
condition:

 Deep breathing exercises are the most basic. The patient should take a deep breath in through his
nose, hold his breath for 3 seconds and then breath out through his mouth. Equipment such as the
incentive spirometer, when available, can help encourage deep inspiration by giving the patient
visual feedback.

Figure 16. Incentive spirometry

 Use of positive expiratory pressure (PEP) which, by increasing the pressure at the mouth, allows
the intrathoracic airways to stay open longer and allows secretions to be moved more easily. PEP
can be achieved by breathing out against a resistance at the mouth, such as the blow-bottle
system where a bottle is filled with 5 to 20cm of water and the patient blows into the water through
a tube which is 30cm long and has a 1 cm diameter (suction tubing can be used). The water
should be changed every day and the bottle and tube every 2 days.
 Position has an effect on lung ventilation and perfusion and the position should be adapted to the
patient’s condition. For bedridden patients, regular change of position is also recommended to
prevent atelectasis and further pulmonary complications.
 Sitting up straight can help open the rib cage.

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BASIC DHS for Nurses

 Patients should not be forced to cough but should not be stopped from coughing by pain.

A sitting position rather than lying down should be encouraged as soon as possible
as it promotes gas exchange.

In children
The two most common causes of acute respiratory distress are bronchiolitis (children
< 2 years) and pneumonia (all ages).

Other common causes of respiratory failure

 Sepsis
 Severe anaemia (malaria)
 Upper airway obstruction and airway obstruction due to an object blocking the airway
 Asthma
 Pleural collection (fluid, pus, blood, air)
 Congenital cardiac failure
 Poisons and drugs (e.g. opiates, benzodiazepines, organophosphates).

Bronchiolitis
A seasonal viral lower respiratory tract infection with bronchiole obstruction. The most likely infecting
organism is the respiratory syncytial virus (RSV) transmitted by saliva, sneezing, droplets from
coughing and cross infection by contaminated hands.
Most of the time, it is not a dangerous infection and the patient does not need to be treated in
hospital.
It mainly affects children under 2 years old and infants under six months old are the most severely
affected as they have smaller airways that are more easily obstructed and they are less able to clear
secretions.
Bronchiolitis is severe if the baby is lethargic (drowsy and lacking in energy), shows signs of collapse
and has a bacterial infection on top of a viral infection.
Symptoms of upper respiratory tract infection are often seen first.
Sign of the severe disease:
 Apnoea, tachypnoea, cyanosis
 Agitation, lethargy
 Sweating
 Signs of respiratory distress
 See-saw breathing
 Nasal flaring
 Use of accessory muscles
 Whinging (crying and unhappy), wheezing, crackles
 Feeding difficulties and dehydration may be present due to increased fluid needs and reduced oral
intake.
 Fever may or may not be present (usually < 38.5°C)
 Condition often gets worse during the first 3-5 days before it improves. Cough and wheeze can
continue for over a week.
 Chest X-rays are not usually necessary and can be normal even the child is sick.
Management and Treatment
Posture
 30° head-up position
 Try to disturb the child as little as possible
Oxygen (refer to the Oxygen supplementation part in this chapter)
 Give oxygen to maintain a saturation of 90-94%
Feeding and hydration
 Oral feeding is always the first choice if there is no risk of aspiration.
 NG tube might be needed and oral feeding with breast milk or formula milk has to be started as
soon as possible with reduced quantity and increased frequency.

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 Acute Respiratory Failure

 IV maintenance fluids are only necessary case of aggravation. Avoid fluid overload, which may
lead to pulmonary congestion and make respiratory problems worse.

Babies in respiratory distress should not be fed by mouth. There is a risk of

aspiration that could lead to pulmonary infection

Medication
 Inhaled bronchodilator therapy if moderate to severe respiratory distress.
 Nebulised adrenaline if no response to salbutamol.
 Antibiotics should not be given as bronchiolitis is almost always due to a virus. If there is a
bacterial infection as well (eg. otitis media, pneumonia, urine infection),antibiotics should be
prescribed by the doctor.
Prevention of cross infection
 If available and possible, keep all the children infected in a separate area. Staff looking after them
should not look after other patients to avoid spreading the infection.

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 Cardiology

Cardiology
Anatomy and Physiology
The cardiovascular system delivers oxygen and nutrients to the body tissues and removes carbon
dioxide and other waste products.

The heart
The heart is above the diaphragm, between the lungs and behind the sternum. It contains 4 chambers:
 Right and Left Ventricles
 Right and Left Atria
Between atria and ventricles, and ventricles and arteries, there are 4 valves (figure 7).
 Tricuspid valve (right heart between atrium and ventricle)
 Pulmonary valve (right heart between ventricle and pulmonary arterial)
 Mitral valve (left heart between atrium and ventricle)
 Aortic valve (left heart between ventricle and aorta)

Figure 1 Anatomy of the heart

The atria are chambers that receive blood from veins. The ventricles are the stronger pumping
chambers that send blood out of the heart through arteries. The pericardial sac surrounds the heart.
The cardiac muscle is called the myocardium.

The circulation
From the left ventricle, blood is sent through the aorta, into a system of branching arteries that lead to
all organs of the body. The blood then flows into a system of capillaries where oxygen and carbon
dioxide are exchanged.

Blood then flows from the capillaries into veins. Veins carrying blood from the upper part of the body
lead to the superior vena cava. Veins draining the lower part of the body lead to the inferior vena cava.
Both these veins empty into the right atrium.

From the right atrium, blood passes into the right ventricle, and then through the pulmonary arteries to
the lungs. In the lungs, blood picks up oxygen from the capillaries, and goes through the pulmonary
veins back to the left atrium..

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BASIC DHS for Nurses

Finally, from the left atrium, blood passes into the left ventricle and out through the aorta to begin the
circulation again (figure 2).

Aorta

Superior vena cava Pulmonary artery

Pulmonary veins
Right atrium

Left atrium
Right ventricle

Inferior vena cava Left ventricle

Figure 2. The circulation

Cardiac contraction
This is divided into systole (contraction) and diastole (relaxation). Both these actions need energy.
Therefore, both may be damaged if the heart is ischaemic (has a reduced blood supply) with an
inadequate blood flow to cardiac cells.

Oxygen and nutrients are delivered to the myocardium through the coronary arteries. As a result of the
high pressure during systole, blood flows to the myocardium during diastole. When the heart rate gets
quicker, the length of both systole and diastole decrease. As a result, tachycardia increases the risk of
ventricular ischaemia, which will worsen cardiac function.

Factors affecting cardiac output

Cardiac output (CO) is affected by the heart rate (HR) and the volume of blood pumped with each
contraction (the stroke volume).

CO = HR x SV

The stroke volume (SV) depends on the volume contained in heart (“preload”), the contractility of the
ventricle, and the resistance against the ejection of blood from the heart (“afterload”).

Preload is closely related to the volume of the ventricle at the end of diastole and is increased by a
larger return of venous blood to the heart. This explains why fluid administration can increase preload.

Myocardial contractility is the strength of the heart during contraction. It can be increased by
sympathetic stimulation and circulating adrenaline and decreased by many drugs, desaturation,
acidosis and conditions such as myocardial infarction, myocarditis13 or sepsis14.

Afterload
Arterial vasoconstriction will increase the pressure in the ventricle and increase afterload.
Vasodilatation will decrease afterload.

13 Myocarditis = Inflammation of the heart muscle, usually due to a viral infection

14 Sepsis = Inflammatory reaction to infection (refer to Severe sepsis and sepsis shock chapter)

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 Cardiology

Factors affecting blood pressure

Blood pressure is determined by the cardiac output (CO) and the degree of vasoconstriction of the
peripheral blood vessels. The degree of vasoconstriction is reflected by the resistance to blood flow
through the blood vessels, which is called the total peripheral resistance (TPR).
MAP = Mean arterial pressure

MAP = Diastolic BP + (Systolic BP – Diastolic BP)/3

MAP = CO x TPR
Heart rate
The heart rate is controlled by specialised pacemaker cells along the myocardium, beginning in the
sinus node.

In children
Cardiac output is mainly dependant on the heart rate, much more than the stroke volume.
Bradycardia and other brady-arrhythmias are poorly tolerated in infants and small children

Homeostasis
Homeostasis is the process of the body adjusting itself to keep systems operating within a normal
range.
The human body is designed to make changes to keep the blood pressure within a normal range. If
the stroke volume falls, the heart rate will increase and the blood vessels will constrict to keep the
blood pressure constant. The blood pressure will only fall if the compensatory mechanisms are unable
to maintain homeostasis.
It is very important to detect these compensatory mechanisms before they become insufficient, in
order to treat any cardiovascular problems as early as possible.

Acute Coronary Syndrome

Coronary arteries supply blood to the myocardium. Because of the pressure generated in the
myocardium during systole, blood flow to the left ventricle only occurs during diastole. Like any other
muscle, the myocardium needs oxygen, glucose and nutrients to contract efficiently. Acute Coronary
Syndrome is due to a decrease in blood flow to the coronary arteries resulting in myocardial
dysfunction. There are two types: severe angina and myocardial infarction

Cardio-vascular risk factors

Factors that will increase the risk of coronary artery obstruction and MI include:
 Tobacco
 Chronic high blood pressure
 High cholesterol levels
 Diabetes
 An inactive lifestyle
 Overweight
 Genetic factors

Angina
Angina is typically a chest pain, constrictive (feels like the heart is being squeezed) and often
spreading to the left arm or angle of the jaw, which is usually worse during physical effort. Tachycardia
and narrow coronary arteries lead to ischemia (lack of oxygen) and pain. The pain should lessen at
rest but may occur at rest in severe cases. Trinitrine (glyceryl trinitrate) sub-lingual spray or tablets are
the most common treatment.

If the treatment does not relieve symptoms, then the patient may be having a myocardial infarction

Myocardial Infarction (MI)

Myocardial infarction is due to the complete obstruction of a coronary artery. Below the obstruction,
the muscle cells don’t receive any oxygen or nutrients, and will die within 6 hours.

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BASIC DHS for Nurses

Clinical signs
 Chest pain, constrictive and often radiating to the left arm or angle of the jaw
 Tachycardia and hypertension
 Anxiety, agitation
 Nausea and sweating
Diagnosis
Symptoms and ECG (if available) confirm the diagnosis.
 Management of coronary patient
 Rest
 Place the patient in a sitting position
 Oxygen to maintain SpO2 >94%
 Monitor and record the vitals closely
 Do an ECG if available
 Insert an IV line
 Medications: Anticoagulant (heparin, aspirin), Trinitrine (vasodilator), Beta-blockers
 Pain management (refer to Pain management chapter): Morphine

Coronary patients have to be considered as an urgent case. Myocardial infarction is a life-threatening

condition.

Severe hypertension in non-pregnant patients

Severe hypertension is diagnosed by a systolic blood pressure ≥180 mmHg and/or diastolic blood
pressure ≥120 mmHg. A hypertensive emergency occurs when elevated BP results in organ injury (eg
stroke, confusion and seizures, renal failure, heart failure,) and hypertensive urgency when there are
no symptoms other than a headache or nose bleed. Detailed clinical examination should be performed
to look for signs of organ injury. Other hypertensive emergencies include ischemic or haemorrhagic
stroke, aortic dissection and acute coronary syndrome

Management of Hypertensive emergencies

 This relies on IV drugs in order to adequately adjust the desired amount of blood-pressure
reduction:
 Nicardipine (2 minutes onset of action)
 Labetalol (5 - 10 minutes onset of action)
The aim is to lower the diastolic pressure to reach 100 to 105 mmHg within two to six hours. Frequent
and regular monitoring of blood pressure is essential (eg every 5 minutes at first).
 Only give enough fluid (5% glucose) to keep the IV line open
 Once vital signs improve, it is no longer necessary to urgently reduce the blood pressure further.
 When hypertensive crisis is complicated by acute pulmonary oedema (APO), the goal is to treat
APO first with IV furosemide, nicardipine and oxygen therapy (refer to Respiratory chapter).

In children
Severe hypertension is very rare. 75% of cases are due to renal disease.
It is defined as:
 Increased systolic or diastolic blood pressure (refer to the normal vital signs tables in the initial
assessment chapter) AND
 Organ injury: usually hypertensive encephalopathy (often associated with seizures).

Management
 Controlled reduction of BP over 48-72 hours
 Use continuous IV infusion of Nicardipine or Labetalol with correct paediatric infusion rates/kg.

Cardiac arrest and cardiopulmonary resuscitation

Cardiac arrest is defined as a total cessation of adequate heart contraction or an extremely inefficient
contraction, which results in an inefficient perfusion of the brain and will cause irreversible damage.

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 Cardiology

The goal of treatment should always be to intervene early, before the patient deteriorates to
cardiac arrest. The outcome of cardiac arrest is generally very poor and so cardiopulmonary
resuscitation should only ever be started in specific circumstances under the direction of a doctor.

Always record the exact time of the cardiac arrest

The three key factors in achieving a good outcome are:

 Early effective chest compressions
 Early reversal of the underlying cause
 Early defibrillation (if available)

Recognition of cardiac arrest

 Unresponsive
 Abnormal or absent breathing
 No femoral or carotid pulse (check for a maximum of 10 seconds)

Figure 3. Feel for the carotid pulse just lateral to the cricoid cartilage

Management of cardiac arrest

Basic life support (BLS)
Early BLS contributes to preservation of heart and brain perfusion and improves survival. Begin with
chest compressions rather than opening the airway and delivering breaths. Shortening the delay
between the cardiopulmonary arrest and the start of chest compressions is essential for the patient’s
outcome.
Every effort should be made NOT to interrupt chest compressions.
Procedure
 Flatten the bed or put the patient on a hard surface, on their back.
 Kneel beside the patient or stand beside the bed
 Place the heel of one hand over the lower half of the sternum

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BASIC DHS for Nurses

Heel of the
hand
Figure 4. Heel of the hand

 Place the heel of the other hand on top of the first hand
 Interlock your fingers, ensuring that you do not apply pressure over the ribs, upper abdomen or
lower end of sternum.
 Lean over the patient so that your shoulders are vertically above the patient’s sternum
 Keeping your arms straight, press down on the sternum, compressing the chest by at least 5 cm
 Release the pressure while retaining contact between your hands and the sternum
 Compression and release should take an equal amount of time
 Compress the chest 100 times per minute (slightly less than 2/sec)
 If there is more than one rescuer, change the person performing chest compressions each time a
pulse check is carried out (approximately every 2 minutes)

Figure 1. Chest compressions

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 Cardiology

In adults, the performance of excellent chest compressions takes priority over ventilation during the
initial period of cardiopulmonary resuscitation. After each 30 compressions give two breaths by bag
mask ventilation, using 10 L/min of oxygen.

Ratio: 30 compressions to 2 breaths

In Children
Asystolic cardiac arrest is more likely in children and is usually the result of desaturation. Airway
opening and ensuring adequate oxygenation may avert cardiac arrest in the deteriorating and
bradycardic child.
Technique of chest compression is age dependent

Post-resuscitation

Monitor the patient closely. A second cardiac arrest is frequent

If the resuscitation was successful

• The doctor needs to perform a physical assessment of the patient to try assess the
underlying cause
• Explain to the patient and their family what has happened.
• Inform the patient’s medical team of the patient’s deterioration.
• Make sure documentation has been completed
• Restock the emergency trolley
• Debrief with other staff

If the resuscitation was unsuccessful

• Provide end-of-life care to the patient
• Inform the patient’s family what has happened and provide support.
• Inform the patient’s medical team.
• Make sure documentation has been completed
• Restock the emergency trolley
• Debrief with other staff

Infection control for CPR

CPR in patients with infectious diseases is a high-risk activity because of the risk of contamination of
staff by body fluids, respiratory droplets and aerosols. Staff protection is essential (refer to Hygiene
chapter).

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 Shock

Shock
Shock is a life-threatening condition where not enough blood flows to the tissues so vital organs do not
get enough oxygen. Immediate medical attention and often ICU admission is needed. Shock is not a
final diagnosis but a symptom of another problem It is therefore important to find out what is causing
the shock so this can be treated.
Normally, the body can provide enough oxygen to meet the metabolic needs of the tissues. When the
body comes under stress, the tissues need more oxygen and the body compensates (adjusts) to make
sure enough blood and oxygen gets to the most important organs (brain, heart, kidney). These
compensatory mechanisms can delay lowering of the blood pressure, which is a late sign of shock.

Factors that affect tissue oxygenation:

 Cardiac output
 Haemoglobin
 Oxygen saturation

Causes of shock
Shock is caused by any condition that reduces blood flow. The major types of shock include:
 Hypovolaemic (including haemorrhagic)
 Distributive: including septic (due to infection) and anaphylactic (due to an allergic reaction))
 Cardiogenic
 Obstructive (occurs when the blood flow into or out of the heart is physically blocked and the heart
cannot pump normally): cardiac tamponade, tension pneumothorax and pulmonary embolism

Management
Management can be divided into standard treatment (that can be used for all types of shock) and
specific treatment (for particular types of shock).

For all shock

Assessment
Hypotension is a strong sign that organs are hypo perfused (not receiving enough blood supply).
However it is possible to be in a shocked state with a normal blood pressure. There is no instrument
that measures organ perfusion directly, however we can use both clinical assessment skills as well as
biological markers to assess organ perfusion.

A normal blood pressure does not exclude the diagnosis of shock

There is no single clinical sign of shock. The diagnosis is made by seeing signs of organ dysfunction
and cardiovascular failure.
Circulatory
 Hypotension: Systolic < 90 mmHg or decrease of 40 mmHg compared to the usual BP
 MAP < 65 mmHg strongly indicates poor organ perfusion.
 Compensatory tachycardia to make sure enough blood gets to the organs
 Weak and thready pulse
 Capillary refill > 3 sec
 Coldness (hypo perfusion and peripheral vasoconstriction) or warmness (sepsis) of limb

When the patient becomes bradycardic, it means they are about to have a cardiac-
arrest

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BASIC DHS for Nurses

Respiratory
 Desaturation, SpO2 < 90% on room air
 RR > 20 bpm
Renal
Urine output <0,5mL/Kg/h
Neurological
 Decreased or altered level of consciousness
 Agitation

In children
How much tachycardia the child has can indicate how severe the shock is. Tachycardia in a child in
shock is more marked than in adults.
Signs of poor peripheral perfusion and compensatory vasoconstriction (cooler hands and feet, a
longer capillary refill time) are useful signs of shock in children.

Hypotension is a late sign of shock

Nursing management of a patient in shock

The most important aim in the treatment is to make sure the tissues have a good blood supply.

Monitor – Record – Respond

Early recognition of poor organ perfusion

 Good initial assessment (refer to Emergency Assessment chapter)
 Closely observe: vital signs, capillary refill time, urine output, temperature
 Get help
Treating the effects of shock, and supporting organ function
 Give oxygen with a high concentration mask (10L/min of O2)
 Insert 2 large bore IV access to enable fluids to be given. Use this procedure for take blood
samples (blood type, cross match, glycaemia, HemoCue, pregnancy test, malaria test or any
further blood analysis).

Think about intra-osseous needle if IV access not rapidly obtained

 If the cause is obviously septic or hypovolaemic (including haemorrhagic) start to give fluids with
1L Ringer’s solution or normal saline given as quickly as possible.
 If the cause is not obvious and the patient does not have respiratory failure or major trauma, raise
the patient’s legs (leaving the head down): if the systolic BP increases by 10 mmHg, give fluids
(eg 500 ml bolus of saline or Ringer’s solution) as quickly as possible

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 Shock

Figure 1. Leg raising

 Make preparations for further treatment that patient may need:

 Fluids resuscitation (Ringer or NaCl 0,9%)
 Blood transfusion
 Drugs such as epinephrine, dopamine
 Insert a urinary catheter so that urine output can be accurately measured. This will help assess
how serious the shock is, if there is any renal failure and whether the correct amount of fluids are
being given. This should be done early but after more life saving procedures have been done.

It is dangerous to give large amounts of intravenous fluids to malnourished

patients (both adults and children). Give fluids carefully following the specific
protocol

Monitor response:
 Blood pressure
 Heart rate
 Peripheral perfusion with capillary refill, skin temperature and colour
 Urine output
 Mental state, consciousness

Hypovolaemic shock
Hypovolaemic shock is due to major fluid loss (blood, digestive fluid).
This loss of volume causes a significant decrease in cardiac filling, which therefore decreases cardiac
output and causes tissue hypo perfusion.
This fluid loss means that less blood is pumped around the body by the heart and therefore the tissues
receive less oxygen

Pathophysiology Cause
Blood loss Trauma
GI bleeding
Ruptured ectopic pregnancy
Incomplete or septic abortion
Obstetrical haemorrhage (placental abruption, placenta
previa, postpartum haemorrhage, rupture of pregnant
uterus)
Dehydration Gastro-intestinal loss: diarrhoea, vomiting, intestinal
obstruction, peritonitis, pancreatitis
Skin loss: excessive sweating, burns
Renal loss: diabetic keto-acidosis
Table 1. Causes of hypovolaemic shock

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BASIC DHS for Nurses

Pregnancy related causes must always be considered in women of childbearing

age

The most preventable type of shock is caused by dehydration during illnesses with severe vomiting or
diarrhoea. Shock can be avoided by replacing lost fluids in the patient that is unable to drink by giving
intravenous fluids.

In children
Hypovolaemia is the commonest cause of shock in children.
Other common causes of hypovolemic shock are:
 Dehydration
 GASTROENTERITIS is the single most important cause
 Not drinking enough
 Diabetic ketoacidosis
 Third space fluid loss15 (peritonitis, bowel obstruction)
 Blood loss from trauma

Signs
 Usually tachycardia and tachypnoea are the first signs. This is called compensated shock which
means the body is trying to make adjustments to itself to keep enough blood going to the tissues.
The patient may not become hypotensive until the condition is about to become life- threatening.
 Cold hands and feet

Anaemia and haemorrhage

It is important to understand that in checking for anaemia, it is the haemoglobin concentration that is
measured, not the total amount. Therefore a change in haemoglobin concentration can occur either
because the amount of circulating haemoglobin has changed, or because the circulating volume has
changed.
When acute bleeding occurs, haemoglobin and volume are lost in the same amounts. At first, there is
no change in the haemoglobin concentration. However, later, fluid moves from the tissues into the
circulation (and non-blood resuscitation fluid may be given). This replaces the volume but not the
haemoglobin so the haemoglobin concentration falls.
The haemoglobin concentration will also fall when fluid that does not contain haemoglobin is given in
response to bleeding.
Anaemia appears as soon as IV volume is restored: Hb concentration is then a sign of blood loss.
A reduction in circulating volume without loss of haemoglobin (e.g. dehydration, burns) will cause a
rise in haemoglobin concentration.

Normal Immediately After fluid

after bleeding resuscitation

Hb 12 g/dL Hb 12 g/dL Hb 7 g/dL

Figure 2. Haemoglobin concentration changes after bleeding

15 Third space fluid loss = movement of fluid into soft tissues and into gut

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 Shock

In children
The diagnosis of hypovolaemic shock in children is often made late because they have strong initial
compensatory mechanisms (tachycardia, intense vasoconstriction) and do not show signs of organ
hypo-perfusion until they are severely hypovolaemic. As well as this, changes in their level of
consciousness as they begin to become hypovolaemic (e.g. anxiety, mild agitation), are often not very
obvious/difficult to detect.

Management and treatment of hypovolaemic shock

 Standard management of shock
 Fluid therapy to restore circulating blood volume

In a shocked patient, when waiting for blood, any crystalloid fluid is better than no
fluid”

 Find out the cause of hypovolaemia and treat it. If the cause is bleeding, then the bleeding must
be stopped. (compression, surgery)

Distributive Shock
Distributive shock happens when the blood vessels in the periphery dilate which reduces the total
peripheral resistance. The cardiac output is often increased, but the body has lost its ability to
distribute blood properly due to the vasodilatation.
Common signs of distributive shock include an increased cardiac output, bounding pulses (strong and
powerful), peripheral vasodilation and tachycardia.
Treatment depends on the cause of distributive shock. The most common cause is severe sepsis, and
less commonly from anaphylaxis (severe life-threatening allergic reaction)
Treatment and management
 Standard management of shock but large fluid volumes are needed.
 Ignore even large differences between fluid input and output in the first 24-48 hours. Well
resuscitated patients usually have a very positive fluid balance in this period.

Proper treatment for sepsis includes treating the cause and giving antibiotics

Treat the cause

After initial resuscitation, treat the cause of the shock as soon as possible. Aim to give antibiotics
within one hour of the diagnosis of severe sepsis but after taking appropriate samples (blood cultures,
swabs etc) if possible.

Don’t delay giving antibiotics to take samples

Investigating the cause of infection

It is important to investigate the cause of infection, and to send samples before giving antibiotics if
microbiology facilities are available and taking samples does not delay antibiotics for more than a few
minutes.
 Blood cultures, 2 samples if possible
 Urine should be dip-sticked for white blood cells and sent for microscopy and culture.
 Respiratory secretions should be cultured if respiratory infection is suspected or if CXR shows
signs of infection.

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BASIC DHS for Nurses

The most likely sites of infection are lungs, urine, abdomen, complicated soft tissue infection (including
infected burns), meninges, IV lines, and bones. Assess all medical devices (ie IV lines, drains)
inserted in the patient, looking for any signs of inflammation. If possible, remove and replace these
under the instructions of the doctor.
Cultures from other sites should be sent if it is possible they could be infected ie wounds.
If respiratory infection is suspected, perform X Ray or ultrasound.

In children
 Hypoglycaemia is common.
 Sepsis can have similar signs to many other conditions and should be considered in any critically
ill child. Infections are the most common cause of death in young children worldwide.
 Children with septic shock often have a low cardiac output with cold peripheries.
 Severe hypovolaemia is common in severe sepsis and septic shock.
 Signs of sepsis are not always obvious, so should be looked for very carefully when treating a
patient with shock.
 A diagnosis of sepsis should be considered if the patient has an altered level of consciousness
that cannot be explanation, agitation or/and tachycardia that continues for longer than normal,
 Children are more likely to develop respiratory failure
 Survival from paediatric septic shock is higher than in adults if it is treated aggressively.

Signs of improvement include:

 Improving mental state
 Heart rate falls to a normal rate for the patient’s age.
 Blood pressure becomes normal for the patient’s age. The blood supply to extremities improves
and pulses can be felt in the hands and feet
 Urine output improves (>1 ml/kg/h).
Anaphylactic shock
A severe allergic reaction.
Clinical Signs
Many of the signs of anaphylaxis are not very obvious but anaphylaxis is likely when all 3 of the
following signs are present:
• Sudden onset and rapid progression of symptoms
• Life-threatening airway, breathing or circulation problems
• Skin and/or mucosal changes (see Table 1).
The diagnosis is also more likely if the patient has been exposed to a substance he is known to be
allergic to.

System Clinical feature

Upper airway Blocked nose, sneezing, hoarseness, stridor, oropharyngeal or laryngeal
oedema, cough, obstruction
Lower airway Dyspnoea, bronchospasm, respiratory distress, cyanosis, respiratory arrest
Cardiovascular Distributive shock, arrhythmias, myocardial ischaemia/infarction, cardiac arrest
Skin Flushing, erythema (redness), pruritus (itching), urticaria,(raised, red itchy areas)
angioedema (swelling of mouth, lips, tongue and upper airway), maculopapular
rash (flat, red area covered with small bumps)
Gastrointestinal Nausea, vomiting, abdominal pain, diarrhoea
Ocular Pruritus, conjunctival infection, eyes running
Neurological Dizziness, weakness, syncope (fainting), fits (rare)
Table 2. Clinical features of anaphylaxis

Management
 If there is any sign of upper airway obstruction, call for help and inform doctor immediately.
 Give high flow oxygen
 Epinephrine is the emergency drug for anaphylactic shock
 Histamine and corticosteroids can also be used
 Remove the substance causing the allergic reaction

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 Shock

Cardiogenic Shock
In cardiogenic shock the tissues are not being perfused because the heart is not pumping properly.
The most common cause is myocardial infarction(refer to Cardiology chapter).
Treated with fluids given very carefully. Dopamine or epinephrine may also be needed. The prognosis
is very poor.

Obstructive Shock
Happens when there is an obstruction to cardiac filling or emptying which decreasing cardiac output.
Most commonly due to pulmonary embolism, cardiac tamponade or tension pneumothorax.
Treatment involves removing the source of obstructive shock, for example treatment of a tension
pneumothorax (refer to Respiratory chapter) or cardiac tamponade (refer to Trauma chapter).

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Neurology
Anatomy

Cerebrum

Cerebellum

Brainstem

Figure 1. Brain

Skull
Rigid bone that acts as a protective covering to the brain and absorbs some energy in case of trauma
The bottom of the skull is irregular. If there is damage or swelling to the brain and it presses against
this surface, contusions (bruising) & lacerations (tearing) can occur.
Lacerations of blood vessels can create brain haematomas (bleeding).

Meninges
Membranes that cover the brain and spinal cord.

Cerebrum
The cerebrum is divided in 2 Hemispheres. Damage to one hemisphere affects the opposite side
resulting in a hemiparesis (weakness) and/or hemiplegia (paralysis).
It is responsible for all higher brain functions eg voluntary movement, language and communication,
memory, sensation.

Cerebellum
The cerebellum connects the cerebral hemispheres with the midbrain and the spinal cord and its
functions are to consciously and unconsciously coordinate muscles, movements, balance and posture.

Brain stem
The brain stem controls cardiac and respiratory functions, maintains consciousness and regulates
sleep.

Blood supply
The brain receives blood from branches of 2 arteries that come off the aorta: the internal carotid
artery and vertebral arteries which divide into a formation of arteries at the base of the brain called the
Circle of Willis. Venous blood leaves the brain via the dural sinuses that drain into jugular veins.

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Cerebro-spinal fluid (CSF)

CSF is a clear liquid, similar to plasma that surrounds and cushions the brain. It is between the
meninges lining the brain and spinal cord.

For meningitis (or trypanosomiasis) diagnosis, a CSF analysis is needed. This is

collected by a lumbar puncture

Physiology
The brain needs a constant supply of oxygen and glucose.
When the oxygen level in the brain lowers, vasodilatation of the cerebral vessels will occur which
leads to an increase of blood volume in the skull.
If the CO2 level decreases, vasoconstriction will occur, which leads to a decrease of blood volume in
the skull.

The brain needs a mean arterial pressure (MAP) between 60 and 150 mm Hg to receive a good blood
supply. The brain can easily be damaged by low levels of oxygen and glucose caused by an
insufficient blood supply. This is why, in the case of shock, an adequate MAP should be maintained by
fluids and vasopressors to reduce this risk.
An ICU monitor gives the MAP automatically after taking the blood pressure of the patient.

Intra cranial pressure (ICP)

The intracranial pressure (ICP) is determined by the contents of the skull:
 Brain tissue: 80%
 Blood volume: 10%
 Cerebrospinal fluid (in the subarachnoid space): 10%

The skull does not expand. With any bleeding, tumour or other expanding condition, the pressure in
the skull (intracranial pressure ICP) will rise. In order to keep the brain blood flow normal the body will
increase the blood pressure (this raised blood pressure should not generally be treated). When this
compensation is no longer effective the brain blood flow will fall and brain damage occurs.
Signs of raised ICP
 Severe headache
 Seizures
 Vomiting
 Changes in motor or sensory function
 Dilated pupil
 Unresponsive pupil

In children
Due to the unclosed fontanelles in very young children, a slow intracranial expansion is possible
without rise of intracranial pressure. Raised intracranial pressure in infants can be diagnosed by
feeling a bulging fontanel (often absent in acutely raised ICP). The sign can be absent in dehydrated
babies.

Neurological assessment
Assessment of neurological function is an essential skill when caring for the critically ill patient.
Assessment of the patient’s neurological function allows the health practitioner to detect abnormalities
and changes in a patient’s nervous system. Assessment of neurological function requires assessment
of:
 Level of consciousness (LOC)
 Posture
 Pupillary assessment
 Vital signs assessment.

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 Neurology

Level of consciousness
Assessing the level of consciousness is the most significant indicator of neurological function and
change in a patient. The AVPU score and the Glasgow Coma Scale (GCS) are 2 tools that can be
used to assess this
AVPU Scale
The AVPU scale is used to quickly assess a patient’s level of consciousness. It is a simplification of
the Glasgow Coma Scale (GCS) that is often used during the ABCDE assessment when the patient is
first seen.
AVPU stands for:
 Alert
 Verbal
 Pain
 Unresponsive
Procedure
Check whether the patient is:
Alert: the patient is fully awake and talking OR
Responsive to Voice: the patient opens his eyes, makes a verbal response or moves after talking to
him, OR
Responsive to Painful stimuli: the patient opens his eyes, moves or talks after a painful stimulus, OR
Unresponsive: the patient does not respond to pain at all.
The patient can only get given one letter: A, V, P or U
Glasgow Coma Scale (GCS)
The GCS is a tool used to perform a thorough assessment of a patient’s level of consciousness.

Test Patient response Score

Eye response Spontaneous 4
To speech 3
To pain 2
Nil 1
Verbal response Orientated 5
Confused speech 4
Inappropriate words 3
Incomprehensible sounds 2
Nil 1
Motor response Obeys Commands 6
Localises 5
Withdraws 4
Abnormal flexion 3
Abnormal extension 2
Nil 1
Table 1. Glasgow Coma Scale (p 98 NURSES)

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BASIC DHS for Nurses

In children
The paediatric Glasgow Coma Scale will be used for patients who are not yet able to talk. The adult
Glasgow Coma Scale can be used for children who can talk (> 3 years).

Score Infant(<1 year) Children(1-3 years)

Eye No modification of scoring criteria required
opening
Verbal 5 Coos and babbles Orientated, appropriate
response 4 Irritable cries Confused
3 Cries in response to pain Inappropriate words
2 Moans in response to pain Incomprehensible words or nonspecific sounds
1 No response No response
Motor 6 Moves spontaneously and
response purposefully
5 Withdraws to touch
4 Withdraws in response to
pain No modification of scoring criteria required
3 Responds to pain with
decorticate posturing
(abnormal flexion)
2 Responds to pain with
decerebrate posturing
(abnormal extension)
1 No response
Table 2. Modified Glasgow Coma Scale for infants and children

Procedure
Talk to the patient and ask him to open his eyes and carry out a simple command e.g. “stick out your
tongue”. If he does not respond shake him to wake him up. If he still does not respond apply a painful
central stimulus such as a trapezius squeeze or sternal rub (figure 2). If he does not localize (see
below) then apply a painful stimulus to each limb. Assess the eye, verbal and motor response to these
procedures as well as looking to see if all limbs move equally.

Figure 2. Central painful stimulus: trapezius squeeze (left) and sternal rub (right)

Eye Response
 If the patient is opening their eyes spontaneously, the score is a 4.
 If the patient has their eyes closed, check to see if they open them to speech. If so, the score is 3.
 If the patient does not open their eyes to speech, then apply pain using a trapezius squeeze
(Figure 2) or sternal rub (Figure 3). If the patient opens their eyes to pain, the score is 2.
 If the patient does not open their eyes to pain, the score is 1.

Open eyes don’t mean that the patient is conscious.

If eyes are swollen and impossible to open, if the patient has eye dressings or nerve damage is
present, C (for closed) should be written.

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 Neurology

Verbal response
 Ask the patient to state the current day and date, location and their name. If the patient is
orientated to all questions, the score is 5.
 If the patient answers questions but is confused about any question related to time, place or
person, the score is 4.
 If the patient cannot answer questions correctly and is not able to participate in conversational
exchange, the score is 3.
 If the patient is moaning or groaning and unable to articulate any words, the score is 2.
 If the patient makes no verbal response, the score is 1.
 Check orientation of the patient in time, place and person
 Time: what is the day today, date, year?
 Place: where are you now (hospital, town)?
 Person: who are you, what is your name?
 Incorrect answers should be corrected at the end of each answer.
 Patients with a tracheostomy will get a T (for tube) for verbal response.

Motor response
 Ask the patient to obey simple commands, such as squeezing hands then letting go and poking
out tongue. If they obey commands, the score is 6.
 If the patient cannot obey commands, apply central pain. If the patient makes a purposeful
movement towards painful stimulus when central pain is applied, then they are localising to pain
and the score is 5 (Figure 3).

Figure 3. Localising to pain. Note that supra-orbital pressure should not be used as a central painful stimulus if the patient may
have facial fractures

 If the patient does not make a purposeful movement to remove the painful stimuli, apply a painful
stimulus to each limb. If they attempt to withdraw from the painful stimuli the score is 4 (Figure 4).

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BASIC DHS for Nurses

Figure 4. Withdrawal from pain

If the patient flexes their elbows rigidly in response to painful stimulus (abnormal flexion) the score is 3
(Figure 5). In this posture, the arms are adducted and flexed. The wrists and fingers are flexed on the
chest. The legs are stiffly extended and internally rotated, with plantar flexion of the feet.

Figure 5. Abnormal flexion

 If the patient extends their arms against the trunk of the body with fists rotated outwards (abnormal
extension, the score is 2 (Figure 6).

Figure 6. Abnormal extension

 If the patient makes no movement in response to painful stimuli, the score is 1.

 The patient should be able to obey 2 different commands per assessment.
 The response to stimuli should be observed in the arms NOT in the legs. Both arms are assessed
and the best response is documented. Responses in the legs are both inconsistent and inaccurate
and may only be a spinal reflex
 If the patient is paralysed, a P (for paralysed) should be written for motor response
Important points
 A change in GCS of 2 points or more represents a significant change in the patient’s condition and
requires a medical review.
 Minimum GCS is 3/15
 Before performing a neurological assessment on a patient, the patient’s history should be
examined in case there are any reasons the assessment might not be correct such as:
 Language or speech barriers: do you speak the same language as the patient or does she
have a problem with speaking or understanding speech?
 Hearing and vision impairments: is the patient blind or deaf?

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 Neurology

 Presence of a tracheostomy: is the patient able to talk?

 Pre-existing neurological pathology (e.g. Cerebrovascular Accident CVA)
 Spinal injury: lesion at level C4,C5 or C6 can give partial or complete paralysis of the arms
and hands in a conscious patient
 Limb paralysis, etc.
 These barriers should be overcome if possible, i.e. with the use of family members, interpreters,
communication aids, hearing aids etc.
 The use of sedative and paralysis drugs should be noted. A GCS should not be performed on a
medically paralysed patient. Sedative drugs may need to be paused to perform an accurate
patient assessment.
 The painful stimulus must be painful. Consider hospital hygiene when using objects to provoke a
painful stimulus (e.g. pen should be disinfected after use).

 Also consider extracranial causes of decreased level of consciousness, such as desaturation,

certain medications and metabolic disturbances (eg hypo- or hyperglycaemia).

Pupillary assessment
Pupillary assessment is used in conjunction with the GCS to detect for neurological dysfunction and
deterioration. Normal pupils are of the same size on both sides, about 2 to 6 mm and round.
Procedure
To assess pupil reaction, make sure that the light in the room is dim. Bring a light source in from the
side of the eye towards the pupil. Observe pupils for size, shape, reactivity to light and consensual
light response. Light shined in the right eye should constrict the pupil in both the right AND the left
pupil at the same time (figure 7)

Figure 7. Upper picture shows pupils before testing. Lower picture shows effect of shining light in right eye. Both pupils get
smaller.

Pupil size and response to light

 Pupils are measured in millimetres using a scale.
 Both pupils should be the same size. Unequal pupils can indicate pressure on the cranial nerve or
brainstem injury. Ask family if they have noticed unequal pupils before or if the patient uses any
eye droplets.

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BASIC DHS for Nurses

 The size of the pupils can be affected by drugs, extremes of cold, desaturation or a lesion inside
the brain.
 The pupils should get smaller (quickly) in response to light and quickly get bigger when the light is
removed.
 Slow pupil reaction can be seen in patients on certain drugs or who have increased
intracranial pressure.
 Nonreactive or fixed pupils do not react to light. This is seen in conditions t such as raised
intracranial pressure, severe hypoxia and ischemia
 Some common causes of abnormal pupil size and response are:
 Pin-point (very small)-opiates
 Large-atropine or trauma to the eye
 Unresponsive dilated pupils –hypothermia, desaturation or during/after a seizure, death
 A dilated pupil on one side can mean that the patient has an expanding lesion on that side of
the brain

Figure 8. Dilated, unresponsive right pupil. Note that the left pupil shows a normal response (smaller in response to light being
shone in right eye

Pre-existing difference in pupil size might exist, ask relatives.

Any change of pupil diameter, shape or reactivity should make you call the doctor.

Vital signs
Cardiac and respiratory centres are located in the brainstem. Changes in a patient’s vital signs can
mean these centres are being compressed due to increased intracranial pressure and impending
herniation (the brain being pushed into a space it does not normally occupy).
The following change in vital signs may indicate a change in neurological state, particularly in the
patient with a low level of consciousness:

 Decreased respiratory rate

 Irregular breathing pattern
 Bradycardia
 Cardiac arrhythmias
 Increased systolic blood pressure

If a patient has a reduced conscious level, always check the blood sugar level as
soon as possible. A low or very high blood sugar level can be the cause of being
confused or unconscious

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Coma
Patients can be unconscious for many reasons. The cause will have to be investigated to start the
correct treatment. An unconscious patient is defined by a GCS < 8.

Most common causes

 Hypoglycaemia
 Ketoacidosis (see Metabolic chapter)
 Intracerebral bleeding, stroke
 Poisoning with drugs, medications or alcohol
 Head injury
 Epilepsy
 Infection (e.g. Meningitis)
 Hypothermia
 Malaria (refer to Malaria chapter)
 Desaturation
 Dehydration

Through history and examination, the doctor will decide which is the most likely diagnosis. Important
questions are the history of trauma, the speed of onset, presence of headaches, use of drugs or
poisons.

In children
Common causes in infants ≤ 3 months old Common causes
(excluding new born babies) in children > 3 months old
CNS infection (meningitis, encephalitis) CNS infection (meningitis, encephalitis, cerebral
Seizures malaria)
Systemic sepsis Seizures
Systemic sepsis
Anoxic-ischaemic injury
Intoxication, poisoning
Table 3. Common causes of non-traumatic coma in children

History
Speed of onset: sudden decrease in consciousness suggests seizures, intoxication or a recent head
injury (sometimes apparently minor).
Progressive deterioration suggests infection or metabolic disturbance
Ask about current drug treatment, possible accidental drug ingestion and traditional medicine.

Management
Never forget, that an unconscious patient is not able to protect his airway. A standard emergency
assessment has to be done (refer to Emergency assessment chapter) and the management has to be
started as soon as possible.

Careful nursing of coma patients saves more lives than even the most expert
surgeon

Positioning of the patient

 If the patient is unable to swallow and to protect his airway, he should be placed in the left
recovery position (unless he has a skull fracture on the left side).
 If the patient is able to protect his airway, the head should be raised to 45° and positioned in a
straight line with the spine (this helps cerebral venous drainage and avoids compression of the
jugular veins (which could increase intracranial pressure).
 The cervical spine of all head-injured patients should be immobilised as soon as possible by using
a stiff-neck collar. The collar should stay in place until a spinal X ray has confirmed that there are
no unstable fractures. The collar must be fitted correctly to avoid pressing on the jugular vein.

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Where possible, immobilise the patient’s cervical spine with sandbags and tape rather than use
restrictive neck collars. (refer to Trauma chapter)

Febrile coma
Fever is an important sign in patients with reduced consciousness because it can indicate a central
nervous system infection. In these patients, it is important to start anti-infective treatment as soon as
possible to minimise mortality and morbidity. This is particularly true for community acquired bacterial
meningitis and cerebral malaria.
In a patient with septic shock (often caused by pneumonia or urinary tract infection), unconsciousness
may be due to the shock. In this case, the level of consciousness should be reassessed after
resuscitation.
Brainstem injury can cause fever due to impaired temperature control.

Take a careful history to find out

 Time fever started.
 Were there any symptoms before coma, such as behavioural changes.
 Headache or vomiting.
 Asymmetrical muscle weakness
 Environment: any outbreaks of disease in the area, season, have any family members been ill?

Lumbar puncture (LP) should be considered

Blood samples should be taken for blood culture (preferably before antibiotic therapy) and for quick
malaria diagnostic testing.

In children: Non-traumatic coma

Haemorrhage and infarction are rare. Meningitis, hyperthermia, hypoglycaemia or desaturation
seizures and intoxication are the most common causes

Meningitis
Meningitis is an acute bacterial infection of the meninges, which may affect the brain and lead to
irreversible neurological damage, hearing impairment and death.

Clinical manifestations
The patient will appear seriously ill. Common symptoms consist of fever, headache, photophobia (light
hurts the patient’s eyes) (Figure 9), neck stiffness, decreased consciousness and change in mental
status.

Figure 9. Patients with meningitis often resist eye-opening as a result of photophobia

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 Neurology

Other clinical signs include Kernig’s sign (Figure 10) and Brudzinski’s sign (Figure 11).

Figure 10. Kernig’s sign. Extending the knee with the hip flexed produces pain in the back

Figure 11. Brudzinski’s sign. Flexing the patient’s neck causes flexion of the hips and knees

In children
In young children (particularly in infants), classical signs of meningitis are frequently absent; one or
more of the following may be the only sign of meningitis:
 Irritability or lethargy
 Poor feeding, abdominal distension or vomiting
 Apnoea
 Hypotonia
 Hypothermia or fever
 A bulging fontanelle (when not crying) can be a late sign of meningitis in infants.
Fulminant Purpura
Is a skin rash usually associated with severe sepsis, especially meningitis. It starts as a red rash that
quickly develops central areas of blue-black haemorrhagic necrosis. Lesions are grouped together,
non-blanching (when pressure is applied over the rash the skin doesn’t lighten), painful and becomes
hardened.
It is a sign of severe infection. The patient needs urgent treatment.

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BASIC DHS for Nurses

Figure 12. Purpura. (©2010 James Heilman M.D. Reproduced under the terms of the Creative Commons Attribution 3.0
Unported License)

Lumbar puncture
Patients with suspected meningitis should have their CSF examined by having a lumbar puncture (LP),
unless there is an epidemic, when the meningococcal bacteria has been confirmed.
LP should not be done in a case of raised intracranial pressure because it may lead to brain herniation.
However, signs of raised intracranial pressure are not always easy to see. Coma and clotting
disorders are other reasons for not doing an LP.
After the LP, the patient should be kept lying flat for 2 hours to reduce the chance of the LP causing
severe headache.

Treatment
Bacterial meningitis is a medical emergency and can be life threatening. Outcome is closely related to
timing of antibiotic therapy, which should be ideally given within 1 hour following arrival in the
emergency room. If an LP is possible, the first dose of IV antibiotic has to be given just after wards so
as not to alter the results of CSF examination.

Meningitis is an epidemic disease. Isolation is part of the management in order to

protect other patients and the staff from contamination

Seizures
Seizures result from excessive or abnormal electrical activity in the brain characterized by involuntary
movements (stiffness and/or rhythmic movements), together with a loss of consciousness, and often
urinary incontinence (generalized tonic-clonic seizures).

It is important to know the difference between seizures and ‘pseudo-seizures’ when consciousness
may appear altered but is not lost (e.g. in hysteria or tetanus).
Most seizures stop by themselves and do not need anticonvulsants to be given. However seizures
lasting more than 1 minute need to be treated. Continuous seizures or seizures that happen regularly,
where the patient does not recover consciousness between episodes, are known as status epilepticus.

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 Neurology

Causes
 Cerebral malaria
 Meningitis
 Epilepsy
 Desaturation
 Eclampsia
 Encephalopathy
 Brain injury, trauma
 Metabolic abnormalities (hypoglycaemia, hyponatraemia, hypokalaemia)
 Alcohol, drugs
 Severe hypertension (note that short term hypertension can also be the result of seizures)

Management
3 priorities: airway management, stop the seizures and determine the cause.
 During the seizure, make sure that the airways are clear, and that the patient can breathe.
Measure glucose. If seizure lasts >1 minute the patient will need diazepam.
 After the seizure, put the patient in a safe position and make sure airway is open (recovery
position, oropharyngeal airway (Guedel))
 Observe the patient until consciousness returns
 Monitor the vitals and supply oxygen if needed
 Obtain history of the patient.
 Treat cause (glucose, anti-hypertension, magnesium sulphate, antibiotics, Arthesunate)
 Give anticonvulsants: Diazepam IV (or midazolam IM), Phenytoin, Phenobarbital, Sodium
valproate

Address any concerns regarding the spiritual significance of the seizures

In children
Hyperthermic convulsions are common in children between 6 month and 5 years without neurological
illness (febrile seizures due to malaria for example).
Management of fever:
 Paracetamol IV
 Uncover the child

Cerebral Vascular Accident (CVA)

A cerebral vascular accident (stroke) is when the blood flow to a part of the brain is stopped, which
prevents oxygen and nutrients getting to the brain tissue. It is caused either a blockage (clot) or a
rupture of a blood vessel. Within minutes, brain cells begin to die. This causes the sudden appearance
of neurological signs such as face drooping, limb weakness on one side and speech difficulty

Management
 Put the patient in the recovery position if comatose
 Call the doctor
 Monitor the vitals
 Provide oxygen if needed
 Suction in case of vomiting

Spinal injury
 Common following trauma
 Causes weakness and sensory loss below the level of the injury
 Management is mainly prevention of further injury by keeping the spine in alignment. Log roll the
patient (figure 12 in the Emergency assessment chapter) and pay attention to preventing
complications of immobilization (see Nursing Care chapter), bladder and bowel care.

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Tetanus
Tetanus is a severe infection due to the bacillus Clostridium tetani, which is found in soil, and human
and animal waste. The infection is not contagious (able to be spread from person to person). C. tetani
gets into the body through a wound and produces a toxin that affects the central nervous system
leading to the symptoms of tetanus.

Tetanus can be completely prevented by vaccination. In unvaccinated people, most breaks in the skin
or mucous membranes carry a risk of tetanus infection, but the wounds with the greatest risk are: the
umbilical cord stump in newborns, surgical wound sites or sites of obstetric procedures done under
non-sterile conditions, puncture wounds, wounds with tissue loss or contamination with foreign
material or soil, tearing and crush injuries, sites of non-sterile injections, chronic wounds (e.g. leg
ulcers), burns and bites

Tetanus diagnosis is made on the clinical signs only so should be considered in patients with muscle
spasms and history of inadequate vaccination.

Clinical signs
 Trismus (lockjaw-unable to open the mouth)
 No decrease in conscious level
 Tetanic spasms:
 May be started off by loud noises or other sensations, such as physical contact or light.
 Painful contractions of skeletal muscles and episodes of intense muscular spasms: patients
clench their fists, arch their back and flex and abduct their arms while extending their legs
(opisthotonus: Figure 13), abdominal guarding, stiff neck.
 Associated with periods of breathing stops (apnoea) and/or upper airway obstruction
 Difficulty swallowing.
 Autonomic overactivity:
 Early: Irritability, restlessness, sweating and tachycardia.
 Later: Profuse sweating, cardiac arrhythmias, unstable hypertension or hypotension, and fever
are often present.

Figure 13. Opisthotonus

In Newborns
 In 90% of cases, the first symptoms appear within 3 to 14 days of birth.

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 The first signs are significant irritability and sucking difficulties (rigidity of the lips, trismus, then
rigidity becomes generalised, as in adults.
 Although the umbilicus is almost always the port of entry, clinical infection of the cord site
(omphalitis) is evident in only one half of cases.
 Check for septicaemia, which is frequently associated.

Management
Hospitalisation is necessary and requires 3 to 4 weeks on average. Correct management can reduce
mortality by 50%, even in hospitals with limited resources.
 Nurse patients with tetanus in a separate ward or room to reduce stimulation (noise, light, physical
contact). All stimulations can cause painful spasms that can cause critical respiratory distress.
Handle the patient carefully, under sedation, and as little as possible.
 Stopping toxin production:
 Wound wash
 Immunoglobulin
 Vaccine
 Antibiotics (Metronidazole)
 Pain treatment: Morphine (close respiratory monitoring is vital + Naloxone readily available, refer
to Pain management chapter)
 Control of muscle spasms by sedation with intermittent or continuous administration of
benzodiazepines (Diazepam, close respiratory monitoring is vital + Anexate readily available).
 Magnesium sulphate may be given to reduce the autonomic over activity.
 Supportive care:
 Airway: Gentle aspiration of secretions. A tracheostomy can be lifesaving, even if
mechanical ventilation is not available, to manage airway obstruction and perform tracheal
suction.
 Early enteral feeding is essential due to the high-energy demands in tetanus
 Prevention of pressure sores and deep vein thrombosis (refer to Postoperative care chapter)
 Physical therapy as soon as spasms have ceased, in order to prevent disability due to
prolonged immobilisation.

Prevention
Pre-exposure prophylaxis: Routine active immunisation (national immunisation programs).
Post-exposure prophylaxis: Prophylactic passive immunisation with tetanus immune globulin (high-risk
wounds) and adequate surgical debridement when necessary.
Appropriate hygiene during delivery and care of the umbilical cord following delivery..
As getting tetanus does not bring about immunity, vaccination against tetanus must be administered
once the patient has recovered. In the case of neonatal tetanus, start vaccinating the mother.

Rabies
Rabies is a viral infection of wild and domestic mammals, passed on to humans by bites from an
infected animal’s saliva, or through this saliva coming into contact with broken skin or mucous
membranes. Any mammal can pass on rabies, but most human cases are due to dog bites.

When symptoms develop, only palliative care can be given. Nurse the patient in a quiet place and
avoid triggers such as water. Treat agitation and pain. Give psychosocial support to patient and family.
(refer to Palliative care chapter).

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Pain management
Accurate assessment and management of pain is an essential role of the ICU nurse, as most patients
admitted to the ICU will experience pain. Pain is defined as an unpleasant sensation that can range
from a mild, localized (in one place) discomfort, to agony.
Pain results from a variety of diseases. Each patient will react differently to pain depending on their
cultural background, age, etc. Therefore only the patient themselves can assess the level of his/her
pain. Regular assessment of how much pain the patient has is very important in order to give the right
treatment.

There are two different types of pain:

 Nociceptive pain is useful because it’s a protective reaction from the body. It usually presents as
acute pain and the cause is usually obvious (e.g. acute post-operative pain, burns, trauma, renal
colic, etc.). This type of pain usually goes away as the injury heals or the cause of the pain
(stimulus) is removed. Treatment is quite well established for this kind of pain.
 Neuropathic pain, due to a nerve lesion (stretching, ischemia), is most often chronic pain (pain
that lasts for more than 3 months). As well as having more or less localized pain almost all the
time, such as paraesthesia16 or burning, there are repeated, acute attacks such as electric shock-
like pain, often experienced together with other abnormal sensations such as anaesthesia, or
hypo or hyperparaesthesia (reduced sensitivity or over sensitivity). This type of pain is often linked
to post-amputation pain, spinal injury, etc.
 Neuropathic pain has no helpful purpose and can have a negative effect on the patient’s life and
that of his family
 Mixed pain (cancer, HIV) for which management requires a broader approach
Pain is not proportional to the extent of injury. However some patients, especially those in ICU, are
often unable to report pain themselves. This can be due to their altered mental state, use of sedative
agents, language barriers, and use of muscle relaxants preventing communication.
As a result, objective pain assessment tools have been developed, with the aim of making sure
patients are free from pain.

Evaluation and self-evaluation are the keys to good pain management

General recommendations about analgesic drugs

 Pain can be treated best if it has been properly assessed
 The patient is the only person who can evaluate how bad the pain is.
 The use of an evaluation scale is essential: NS, SVS (see below)
 Results of pain evaluation should be recorded with other vital signs
 The sooner the treatment is started, the better the efficiency will be
 It is best to give drugs before the pain starts
 Prescription and giving of pain killing drugs should be systematic and at fixed times, and a “if
needed” prescription should be done between the fixed times.
 It is best to give the drugs by mouth if possible, instead of IV, IM, etc.
 A mix of different painkillers is usually most effective and should be used whenever possible

Using a combination of different painkillers increases efficiency

Clinical signs often associated with pain

 Tachycardia (this increases oxygen needed by the heart)
 High blood pressure

16Paraesthesia = abnormal sensation like tingling or pricking resulting from pressure on or damage to
peripheral nerves

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 Facial grimacing
 Agitation and restlessness (insomnia, anxiety, stress)
 Patient does not want to move (risk of bedsore or DVT) or cough (risk of respiratory failure)
 Ventilator dysfunction

Reducing pain during hospitalization reduces the risk of chronic pain

In children
 Children, including neonates and infants, feel and remember pain and discomfort.
 Under-treatment of pain in children is more common than in adults.
 Assessment of pain is more difficult. Young children cannot evaluate their own pain due to
difficulties with communication and understanding. Older children over 5 years old are
often able to report their pain. Note that sick children in hospital often go back to behaving
more like younger children. Use simple observational pain scoring tools for children < 5
years old (or if self-reporting is not possible in an older child, see figure 1).
 Use verbal descriptive scale for older children whenever possible.

Pain assessment tools

When using the scales it is important that the patient understands the scale and
understands the difference between pain and low mood before using it

Self reporting
In a self-reporting evaluation, the patient evaluates his own pain. It’s very important to explain the
scale used.
SVS: Simple verbal scale for patient > 5 years old
0: no pain
1: mild pain
2: moderate pain
3: intense pain
Numeric scale (NS)
To assess how severe the pain is, a number scale can be used where the patient is asked to score
their pain out of 10, with 0 being no pain and 10 being extreme pain (jumping out the window pain).

In children
Faces Pain Scale for children

Figure 1.Face pain scale.

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Ask the child to select the face corresponding to their level of pain, making sure that the child
understands that you want to know about pain not mood. From the face selected you can obtain the
corresponding numerical score.

With the faces pain scale, be careful not to confuse sadness with a baby crying
from major pain

If a patient is unable to self report their pain, then an objective pain assessment tool should be used.

Objective pain assessment tool

In Children
FLACC (Face, Limbs, Activity, Cry and Consolability)
For patients < 5 years old
Based on the observation and the rating of 5 items, each with a value from 0 to 2.
Maximum score of 10 points.
0-3: mild pain
4-7: moderate pain
7 to 10: intense pain

0 1 2
Face No particular expression Occasional grimace or Frequent to constant
or smiling frown, withdrawn, frown, clenched jaw,
disinterested quivering chin
Legs Normal position or Uneasy, restless, tense Kicking or legs drawn up
relaxed
Activity Lying quietly, normal Squirming, shifting back Arched, rigid or jerking
position, moves easily and forth, tense
Cry None (awake or asleep) Moans or whimpers, Cries steadily, screams or
occasional complaint sobs, frequent complaints
Consolability Content, relaxed Reassured by occasional Difficult to console or
touching, hugging or comfort
being talked to,
distractable
Table 1. FLACC

NFCS scale (Neonatal Facial Coding System)

Items Scoring
0 1
Brow bulge NO YES
Eye squeeze NO YES
Nasolabial furrow NO YES
Open lips NO YES
Table 2 NFCS scale

A score of 2 or more indicates significant pain and requires analgesic treatment

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Figure 2 Components of Neonatal Facial Coding System

Selecting a pain management plan

After assessment and identification of the pain and how severe it is, the next step is to manage the
pain correctly to relieve it as much as possible. Choose a pain management plan based on how
severe the pain is. The WHO uses a scale that describes 3 levels of pain and what to do for each
level

Figure 2. Select a strategy based on severity of pain

 Mild pain: The use of non-opioids, such as paracetamol, non steroidal anti-inflammatory drugs
(NSAID) e.g. paracetamol, aspirin, ibuprofen, NSAID.
 Moderate pain: The use of weak opioids, such as codeine, and/or non-opioid and adjuvant drugs
and/or local anaesthesia, e.g. tramadol, codeine.
 Severe pain: The use of strong opioids, such as morphine, and/or non-opioids, adjuvant drugs,
local anaesthesia. This level of pain requires fast-acting pain relief, e.g. Morphine, oxycodone,
hydromorphone, pethidine

Giving a strong opioid together with paracetamol is much more effective than either drug given alone
(the combination of pain killers increases each drug's power). For example, you can have a medical
prescription with paracetamol and tramadol or morphine.

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Pain changes, so needs to be re-assessed regularly to make sure the correct pain
killers are given.
Re-assess the pain scale after giving any painkillers to check how effective they
have been.
Don’t wait until pain starts but ask the doctor to plan pain treatment over the whole
day to treat pain and to prevent it.
Give pain medication before painful treatment such as physiotherapy and wound
care

Ways of giving painkillers

Oral or Enteral (tube feeding)
Use oral route whenever possible, as soon as the patient can drink. IV route should only be used
when the patient can’t take drugs by oral route or is not absorbing them reliably.
Easy to give
Works slower
The effect varies depending on how well they are absorbed by the GI tract.

Subcutaneous (SC)
 Useful route of administration if oral is not available.
 Should be avoided for long term, repetitive dosing.

Intramuscular (IM)
 Injection is painful
 Absorption is unreliable especially in critically ill patients
 Generally should be avoided if more than 1-2 doses are required.
 Contraindicated for patients with anti-coagulation treatment

Intravenous (IV)
 Works quickly
 Close monitoring of the drug effect and side effects is needed. Good knowledge of the
medications given is very important.
 Use for acute severe pain.

Opioids
Reduce the sending of pain messages to the brain and reduce feelings of pain. They can have severe
side effects. Close monitoring is needed.

Administration
 Opioids can be given orally, with sub-cutaneous injection and with intra-venous injection.
 Intra-venous injection is only safe in a highly monitored area (e.g. operating room, recovery room,
and ICU).
 Titration (starting with a small dose and repeating until the desired effect is achieved) is the more
common way to manage severe pain with IV morphine.
Morphine titration (medical prescription)
 2 mg bolus IV, repeated every 5 minutes according to the pain evaluation, with a maximum of
10mg.
 3 extremely important rules in morphine titration:
 Assess pain level with adapted scale
 Asses conscious level
 Assess respiratory rate (RR)

Monitoring
Respiratory depression is a major side effect of opioids, it can happen when too high a dose is given.

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 Monitor patient’s sedation and respiratory score (table 3). Tell medical staff if sedation score or
respiratory score >1
 Assess for airway obstruction, such as snoring and or noisy breathing.
 Identify and manage excessive sedation and respiratory depression (score >1).

Sedation score Respiratory score

S0 Awake R0 Regular respiration, no breathing
difficulty and RR ≥ 10/min
S1 Intermittently drowsy, easily awakened R1 Snoring and RR ≥ 10/min

S2 Drowsy most of the time, responds to R2 Irregular respiration, obstruction,

voice chest indrawing, RR < 10/min
S3 Drowsy most of the time, responds only R3 Respiratory pauses, apnoeas
to physical stimulation
Table 3. Sedation and respiratory score

Side effects
The most important side effects are sedation and respiratory depression (see below)
Others include:
 Constipation, ileus (slowing the contractions that move contents of the GI tract forwards)
 Nausea, vomiting
 Confusion, excessive feeling of happiness brought on by drugs
 Itching, skin reaction

Risk of side effects does not mean opioids should not be given but the patient but
needs to be closely monitored

Management of respiratory depression due to opioids

If the patient is drowsy, responds only to physical stimulation, or worse, in coma, you should suspect
that too much morphine has been given. Irregular breathing, low RR (<12 rpm) and desaturation are
also useful signs, but occur later than excessive sedation.
If you are worried, tell a doctor immediately and start basic airway techniques (refer to Emergency
assessment chapter)

Airway obstruction and respiratory depression (low RR) can occur with a normal
SpO2, especially if the patient is receiving oxygen

To treat respiratory depression (RR < 12 rpm)

 Stop opioid treatment immediately and all drugs that could be making the patient drowsy
 Verbal stimulation: talk to the patient and tell them to breathe
 Make sure the airway is open, if necessary use airway manoeuvres and/or oral airways (Guedel)
 Painful stimulation if necessary
 High-flow oxygen, monitor the SpO2 with a pulse oximeter
 Call for help
 Give antidote, Naloxone (Narcan) if :
 Patient is difficult or impossible to wake up with physical stimulation.
 There is significant respiratory depression (apnea, respiratory pauses)
 Prescription: 40 µg IV bolus every minute until RR > 10/min. If no IV access, give 100µg IM or SC,
to be repeated hourly if necessary
 If required, start cardiopulmonary resuscitation; naloxone is given at the same time

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 Naloxone has a shorter effect than morphine, respiratory depression could reappear and it may
be necessary to repeat the dose

Naloxone should always be available where morphine is used and the protocol on
how it should be given must be easily available

Management of other side effects

 Constipation
 Check if bowels have been open daily
 Encourage the patient to eat foods high in dietary fiber
 Inform the doctor and ask for laxative drugs prescription
 Nausea, vomiting
 Tramadol
 Consider giving orally first as this has the least side effects.
 In IV, given in infusion of minimum 100ml of normal saline over 15 to 30 min.
 Contra-indicated in patients with convulsions, epilepsy.

 Morphine
 Giving IV has a high risk of nausea, vomiting. If possible, give orally or by subcutaneous
injection.
 Anti-emetic medications can be given (Ondansetron, Metoclopramide…)

It is unusual for the patient to become tolerant or addicted to opiates if they are
only used for a short time for acute pain relief

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Pharmacology of painkillers
DRUG Form Peak action Dosing Precautions
interval
Paracetamol Tablets 1-2 h 6h Contraindications
- liver failure
Syrup 30-60 min 6h
Injectabl 30-60 min 6h
e
Ibuprofen Tablets 60-90 min 8h Contraindications
- kidney failure
- uncorrected dehydration or
Syrup 60-90 min 8h hypovolaemia
- GI tract ulcer
- active bleeding
- coagulopathy
Diclofenac Injectabl 30-60 min 12 h - child < 6 months
e - elderly patients
- pregnancy
- breast-feeding
- allergy
Tramadol Tablets 1-2 h 6h Contraindications
Drops 15-30 min 6h - severe respiratory failure
(1 drop - untreated epilepsy
= 2.5 - meningitis
mg
SC/IM 30-60 min 6h
Slow Contraindications
Morphine release 2-4 h 12 h - moderate to severe respiratory
tablets failure
- head injury
- drowsiness
- child < 6 months
- elderly patients
SC/IM 30-60 min 4-6 h
Be careful when giving together with
following drugs :
- sedatives
- neuroleptics
- antihistamines

Injectable paracetamol has no advantage over oral paracetamol in patients who

can take drugs by the oral route, effect is the same

In Children
Analgesic and sedative drugs should be prescribed, prepared and charted according to body weight,
such as mg/kg, mcg/kg/hour
In children aged between 0 and 3 months, extra care should be taken with doses due to differences in
drug handling and drug responses.

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 Pain

Respiratory monitoring
Age Lowest Normal Respiratory rate/min
Newborn 40
1 to 12 month 30
1 to 4 years 20
5 to 12 years 15
> 12 years 10

Nitrogen monoxide
Nitrogen monoxide-oxygen mixture (also known as MEOPA or Entonox), is a medical analgesic gas
(nitrous oxide 50% and oxygen 50%).
It’s very useful for providing pain relief for a short procedure (< 45min) for adults or children:
 Dressing burns
 Stitches
 Treating fracture or dislocations
 Any short procedure that can cause pain for the patient

It is effective from 30 seconds after first being given and is removed by the lungs in 1 min.

Normal effects
 Loss of hearing, smell, taste
 Loss of sensation of pain, temperature, pressure
 General relaxation, instant memory loss and euphoria

Side effects
 Nausea and vomiting are the most common side effects. There is little risk of aspiration because
the laryngeal reflex is still present.
 Anxiety associated with feelings of “falling” and “loss of control”
 Mouth paresthesia (tingling)
 Bradycardia, desaturation and apnoea can occur rarely (immediately stop the nitrous oxide, give
high flow oxygen, stimulate the patient)
 Side effects are rare and quickly reversible, but the risk increases when used together with
opioids or benzodiazepine treatment”

Contraindications
 Unstable head trauma with potential intracranial hypertension or confusion
 Pneumothorax, Pulmonary embolism, COPD
 Abdominal distension
 Unconsciousness
 Facial trauma

Procedure
 The procedure has to be explained to the patient and accepted. The patient will manage the mask
on his own.
 Use a high concentration mask. The bag should always be inflated by the gas (min 7L/min so
inflate the bag before connecting the mask to the patient. Choose the correct mask size without a
leak.
 It should not be used for more than one hour per day during one week
A member of the medical staff must stay with the patient and monitor him during the entire procedure.
Nitrogen monoxide is a simple, safe and easy procedure that may be used for any short procedure in
any department, by doctors or nurses, for almost any patient.

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Other methods
Physical methods
 Immobilisation
 Comfortable position (use pillows)
 Ice packs, local cooling
 Massage
 Proper splinting of fractures
 Protect wounds from being accidentally knocked

Others
 Musical therapy
 Deep breathing exercises
 Relaxation, silence
 Sugar and suckling for babies

Any type of pain is unpleasant and frightening. A kind and reassuring doctor or
nurse and a simple explanation of the cause and likely length of time the pain will
continue, can dramatically improve a patient’s ability to cope.

In children
It is important for the parents to be with the child to help reduce their anxiety and fear. Non-drug
methods include frequent communication and reassurance, touch, distraction techniques, hypnosis,
and music as well as environmental noise reduction. Surroundings should be as comfortable and non-
threatening as possible. Talk to the child and explain procedures/ care even when the child is young,
deeply sedated or comatose. Consideration of physical factors that may cause discomfort or stress is
also important (such as urinary retention, hunger, poor sleeping).

Giving a small volume of a concentrated glucose solution orally reduces pain from short, mildly painful
procedures in infants < 3 months (e.g. IV cannulation, NGT insertion). Use 1-2 ml of 30% glucose on
a pacifier (dummy) 2-3 minutes before procedure.

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 Nutrition

Nutrition
Nutrition and feeding are very important for any critically ill patient. ICU patients are at a higher risk of
malnutrition due to higher metabolic demands in response to stress. ICU patients need more calories
and protein than a healthy person. Malnutrition is associated with increased disease and death rates
due to factors like damaged immune function and poor wound healing. The goal of nutritional support
in ICU is to stop malnutrition and its associated complications. Nutritional support is a therapy that
reduces the metabolic response to stress and helps with the immune system. It is important to
remember that certain groups of patients have particularly increased nutritional needs, such as
patients with burns or sepsis.

When should nutritional support be given?

It is better if nutritional support is started within 24-48 hours of ICU admission, unless indicated
otherwise.
 Make sure that there are no reasons why the patient cannot be fed or that the medical staff have
requested they be not fed for any reason. If the patient is able to eat but is not reaching the right
nutritional goals, consider adding oral supplements (eg high calorie biscuits or paste)
 Find out whether the patient can eat on his or her own. If the patient has a decreased level of
consciousness, forcing the patient to try to eat and drink may cause aspiration (liquids or food
pass into the lungs instead of the stomach). If the patient is too sleepy to swallow normally, (for
example, after sedating medications) wait until they are fully awake before trying to feed them or
consider inserting a naso-gastric tube and starting feeding after checking with the medical team.

Enteral feeding (feeding via the gastro-intestinal tract)

Enteral nutritional (EN) is the most suitable and safe way to give the patient the nutrition they need.

Advantages:
 improves wound healing
 protects lining of the intestinal tract
 helps keep it functioning normally
 reduces hospital-acquired infection
 decreases mortality

Enteral feeding is done with a nutritionally complete liquid formula (such as Sondalis®) given through
a naso-gastric tube directly into the stomach.

Indications
 Any patient who is not able to eat enough to match their nutritional needs and who doesn’t have
any reasons why it would not be safe for them to have enteral feeding
 It must be possible to get to the patient’s stomach, usually through nasogastric tube

Contraindications (situations when it is not safe for the patient)

 Gastrointestinal perforation, bowel obstruction or peritonitis
 Abdominal distension or profuse diarrhoea
 Upper gastrointestinal bleeding
 Unstable shock states
 Cardiac or renal failure with fluid overload, fluid/electrolyte imbalances
 Terminal stage of disease or palliative care
 When nasogastric tube is contra-indicated (eg facial or head trauma)
 Decreased level of consciousness (GCS <8)

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BASIC DHS for Nurses

Naso-gastric tube insertion

Figure 1a. Equipment required: Radio-opaque NG tube, stethoscope, tape, lubrification jelly, 60 cc syringe, drainage bag
(optional)

Figure 1b. Measure the length from the tip of patent’s nose, loop around the ear and then measure down 5 cm below the
xiphoid process. Mark the tube at this level.

Figure 1c. Lubricate the end of the tube with KY jelly

Figure 1d. Insert the tube into one of the patient’s nostrils. The tube should be directed straight towards the back of the patient
as it moves through the nasal cavity and down into the throat. When the tube enters the oropharynx and glides down the
posterior pharyngeal wall, the patient may gag. Ask the patient to swallow or give them some water to sip through a straw. Then
continue inserting the tube as the patient swallows. Once the tube is past the pharynx and enters the esophagus, it is easily
inserted down into the stomach.

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 Nutrition

Figure 1e. To make sure the tip is in the correct place, aspirate (draw up) some fluid from the tube with a syringe and test
acidity with pH paper. If the pH is 100, the tip is probably in the stomach. Confirm with a chest X-ray if available.

Figure 1f. Another method is to listen with a stethoscope. Inject air into the tube. If air is heard in the stomach using a
stethoscope, the tube is probably in the correct position. Take a chest X-ray to confirm.

Figure 1g. Secure the tube with micropore tape.

A NG tube should never be inserted in a patient with facial or head trauma. There
is a risk of inserting the tube into the brain.

Complications of enteral feeding

Associated with feeding tube insertion Associated with feeding
Trauma and bleeding of nasopharynx Infection from bacterial contamination of feed
Perforation, abscess of retropharyngeal Nausea, abdominal discomfort and distention
space (bloating)
Oesophageal perforation Regurgitation or vomiting, diarrhoea
Gastric perforation, bowel perforation Pulmonary aspiration of feed
Pneumothorax, pulmonary haemorrhage, Potential for reactions with enteral medications
pneumonitis, pleural effusion, empyema

If vomiting
 Stop feeding
 Check position and that the NG tube is not blocked
 Ask the doctor to prescribe anti-emetics medication
 Restart feeding 8 hours later at half the original flow rate (or half the original bolus volume) for 12
hours

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Make sure there are no signs of aspiration (desaturation, cough, respiratory

distress…)

If aspiration occurs
 Immediately stop feeding
 Aspirate NGT then place on free drainage,
 Give oxygen
 The doctor will prescribe IV antibiotics
 Repeat chest X-ray if possible to make sure the tube hasn’t gone into the lung.

Nursing management
 Enteral nutrition should be started at a low rate and increased to the correct rate slowly so it can
be seen that the feed is being absorbed properly.
 The patient should be watched for signs and symptoms of intolerance of enteral nutrition (such as
nausea, vomiting, abdominal distention, constipation and diarrhoea).
 Some feeding tubes can be aspirated (fluid can be sucked up with a syringe) if the patient vomits,
or there is a special clinical situation ie (after digestive surgery when you need to check there is
no ileus).
 The use of medications that improve the contractions of the gut (metoclopramide, erythromycin)
or stool softeners may be needed if symptoms continue.
 The patient should be watched for re-feeding syndrome, a syndrome caused by restarting feeding
in a malnourished person. The symptoms are electrolyte disturbances, particularly low phosphate
levels.
 Blood sugar levels should be checked every six hours to detect hyper- or hypo-glycaemia.
 Medication can be crushed and given by NGT (except enteric coated). Doing so, be sure to
regularly flush the feeding tube with drinkable water after each dose to avoid blocking the NGT.
 If the NGT has to be aspirated after medications are given, (ie the patient vomits), the absorption
of the medication will be uncertain. The NGT should remain clamped for 2 hours after giving the
medication.
 The patient's weight and arm circumference should be checked regularly
 Check to make sure all medications given through the feeding tube are able to be given with
enteral nutrition. Some medications, such as warfarin and phenytoin, require the feeds to be
turned off before and after giving the drug. And always flush with drinkable water after giving
medication to clean the tube and make sure medication is in the stomach.
 If enteral feeding has to be stopped for any reason, check regularly for glycaemia and adapt
insulin dose.
 Check the skin on the nose and make sure there are no sores due to the tape.

Remember that before beginning feeding and giving any medication, it is

absolutely essential to make sure the feeding tube is in the stomach by listening
for sounds in the stomach with a stethoscope when air is injected or/and by
attempting to aspirate gastric contents with a syringe.

In children
How children differ from adults
 The smaller the child the lower the reserves in terms of calories, protein, water content and even
trace elements and vitamins. The low reserves in association with high metabolic rates mean that
children become malnourished quickly
 Nutrition requirements and the correct fluid intake often conflict

Key points
 Many patients are already malnourished at the time of admission to intensive care

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 Nutrition

 Nutritional needs of children in ICU are very different for different patients
 In the severely ill patient some nutrition should be started early and increased as tolerated.
 Enteral nutrition is generally better than any other route.
 In general, use the smallest bore nasogastric tube available as a route for enteral nutrition.
Smaller bore tubes may be more difficult to pass (they tend to curl up if there is any obstruction to
passage), and if there are significant collections of gas or liquid in the stomach, it is very difficult
to drain them effectively with small bore tubes.
 However larger bore tubes are more uncomfortable and may be associated with unpleasant
pressure effects. Always make sure a nasogastric or naso-duodenal/naso-jejunal feeding tube is
in the correct position, by checking for pH of gastric aspiration or by taking a chest X-ray, before
starting feeds.

The principles of enteral feeding include

 Start slowly and assess: gastric residues (amount of feed left in the stomach) and abdominal
distension
 Stop feeding if the abdomen is distending; if there are bilious vomits or if the gastric residues
exceed 50% of the volume given over the last 4 hours.
 Increase feeds over 12-24 hours until the patient is tolerating the required volumes
 In malnourished patients increase feeds more slowly

Starting enteral feeding

 In infants who are breast-fed, start on expressed breast-milk as soon as possible
 In formula fed infants, start with a milk preparation that is as close as possible to their normal feed
 In older children start with enteral formulas that do not contain lactose
 In general, get children onto a diet which is close to their normal diet at home as soon as
possible.

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Blood transfusion
Indications
Anaemia:
Anaemia is present when the haemoglobin concentration in the peripheral blood is lower
than normal for age, sex, pregnancy, and environmental factors.
Haemoglobin is the red blood cell protein responsible for carrying oxygen from lungs to all
the organs.

Haemoglobin concentration is one of the factors that affect oxygen delivery

Oxygen delivery depends on:

 Cardiac output
 Haemoglobin
 Oxygen saturation (SpO2)

ANAEMIA (g/dL)
New born < 13,5
Infant 2 – 6 months < 9,5
Infant 6 months – 6 years < 11
Child 6 – 12 years < 11,5
Man < 13
Woman < 12
Table 1. Age-related definition of anaemia. Adapted from Clinical use of blood, OMS, 2005.

Causes

Anaemia is not a diagnosis

 Problems with red blood cell production (malnutrition, medullary aplasia, infection like HIV or
visceral Leishmaniasis)
 Loss of red blood cells (haemorrhage)
 Destruction of red blood cells (malaria, sickle cell anaemia, thalassaemia (inherited disorder
which results in the production of abnormal haemoglobin), infection)

Clinical signs of anaemia

 Severe anaemia may cause pale conjunctiva (mucous membranes inside the eyelid), but this is
not very reliable. Look at the gums and palms as well. Conjunctival pallor may also be a sign of
hypovolaemia or shock with normal haemoglobin.
 Lethargy, weakness
 Dyspnoea
 Tachycardia

Life threatening anaemia

Signs
 Sweating
 Thirst
 Signs of shock

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Treatment and management

 Give high flow oxygen
 Look for and stop bleeding
 Check HemoCue. Remember that the HemoCue will be normal in the early stages, even in
severe active bleeding.
 Check blood group if patient is likely to need blood (see table 3) and insert IV line
 Call doctor for blood transfusion prescription

Anaemia without hypovolemia

Table 2 list situations in which you should consider giving blood to a patient that is not hypovolaemic.

Children Including severely malnourished

children)
Hb < 4 g/dl Yes
Hb 4 - 6 g/dl If clinical sign of de-compensation
Hb > 6 g/dl No, except if specifically indicated
Pregnant women
Hb ≤ 5 - 6 g/dl Yes
Hb < 7 - 8 g/dl If clinical sign of de-compensation, malaria,
pneumonia or other severe bacterial infection,
cardiac diseases.
Hb < 8 g/dl Caesarean section plan => 2 units ready to be
transfused
Adults
Hb < 7 g/dl If severe malaria
If major surgery with haemorrhage risk for a
stable patient => 2 units ready to be transfused
Table 2. Indications for blood transfusion in non-hypovolaemic patients

Basic transfusion rules

ABO
Different people have different blood groups. Patients with certain blood groups can only receive
blood of certain groups and therefore it is important to test that the blood is compatible. There are
several stages to this process.
Table 3 and figure 1 show what blood types can be given to patients with different blood groups. It is
important that you check that the group of the blood being supplied is appropriate for your patient.

Recipient Blood unit

1st choice 2nd choice 3rd choice 4th choice
O O XXXXX XXXXX XXXXX
A A O XXXXX XXXXX
B B O XXXXX XXXXX
AB AB A B O
Table 3. Choice of ABO compatible blood

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 Blood transfusion

Figure 1.Diagram showing which blood groups can be given to different patients. For example group O blood can be given to
patients of all groups, but group O patients can only receive group O blood.

Rhesus
The Rhesus system is also an important system to consider when transfusing women of child bearing
age and girls. Giving rhesus positive blood to rhesus negative women and girls may result in later
problems in their newborn children.

Procedure
It is important to strictly follow the protocol used in your hospital for grouping the patient and
transfusing blood. In particular, it is essential to make sure that there is no chance of mixing up blood
samples from different patients, and that the sample is clearly labelled with the correct and complete
patient details. When the units of blood are delivered, it is essential to check that only compatible
blood is given to the patient, that the blood has not expired and stored blood has been kept cold.

During transfusion, monitor vital signs and any symptoms very closely (0, 5, 10, 15, 30 minutes and
every 30 minutes after that, until the end of the transfusion). While the blood is being given, record all
the information on the monitoring form. The IV line used for the blood transfusion should not be used
for any other purpose”

At the end of the procedure

 Check the vital signs and re-assess the patient
 Keep the IV running slowly
 Keep the empty blood bag for 2 hours after the end of transfusion so it can be checked in case
the patient has a reaction
 If the patient’s clinical condition is better, it may not be necessary to check Hb after the blood
transfusion.

A complication can happen even after the blood transfusion has finished so it’s
very important to keep the empty blood bag for two hours after the end of the
transfusion, in order to analyse the blood and find the cause.

Adverse effects
Transfusion is associated with a number of complications. Acute life-threatening complications include
acute haemolytic transfusion reactions, fluid overload, severe allergic reactions, septic transfusion
reaction and blood-borne infections.
Consider the possibility of an acute transfusion reaction and call the doctor if the patient develops any
of:
 Fever
 Chills
 Rigors
 Tachycardia
 Hypo or hypertension

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 Desaturation
 Flushing (redness)
 Urticaria (skin rash)
 Bone/muscle/chest/abdominal pain
 Nausea
 Respiratory distress
 Generally feeling unwell

Acute severe transfusion reaction

Acute severe transfusion reaction is more likely to occur in the first 15 minutes of transfusion

Figure 2. Signs of acute severe transfusion reaction

Treatment of acute severe transfusion reaction:

 Stop transfusion
 Give high flow oxygen and call the doctor immediately in emergency (red case)
 Keep the IV catheter. A second IV line could be helpful but should not delay other treatments.
 Start infusion of a 500 ml bolus of saline over 20 minutes to ensure adequate fluid loading.
 Monitor the patient closely: HR, BP, SaO2, RR, T° every 5 minutes, urine output (urinary catheter
is essential)
 Take a blood sample to repeat blood grouping
 Check for haemoglobinuria with urine strip (dipsticks/multistix).
 Blood unit and administration set need to be send to blood bank, along with all other used and
unused units.

Other acute adverse effects:

 Allergic reaction
 Bacterial infection
 Acute pulmonary oedema
 Mild febrile reaction

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 Trauma

Trauma
Identifying and treating injuries early can prevent complications and even death of the traumatized
patient.
Patients with severe trauma are difficult to manage, due to the large number of possible injuries and
the initial need to resuscitate the patient while identifying injuries. As mentioned before, you should
prioritise (decide on the most important) tasks in the initial stages, constantly re-assess priorities and
repeatedly re-assess the diagnosis as more information becomes available.

Preparation is important: check that the resuscitation area is ready at all times, before any critically ill
patient arrives.
 Emergency trolley in the resuscitation area with necessary emergency medications and
equipment
 Adequate supply of resuscitation fluid (Ringers or saline) and safe blood for transfusion
 Equipment to stabilise the cervical spine and a spinal board to move the patient, if necessary

Following a trauma resuscitation, restock any used equipment, medications, and

IV fluids. Check the emergency trolley and oxygen cylinder at least twice daily

Good teamwork is needed for successful management of trauma cases. Deciding on a team leader is
essential from the start. The team leader is responsible for coordinating the efforts of the individual
team members and developing an overall management plan. Team members should concentrate on
their own tasks while staying aware of the overall plan and progress. Effective communication
between the team leader and all team members (doctors, nurses and other staff) is essential (refer to
the Handover chapter).

Early resuscitation should be carried out immediately while pre-hospital staff (ambulance, police, other
witnesses) are handing over. Pay attention to the type of injury.

For all trauma

Specific considerations in the emergency assessment of the patients with major trauma.
 Airway. Avoid a head tilt in patients with all major trauma, use a modified jaw thrust instead
 Check breathing. Is the chest moving symmetrically, are there signs of respiratory distress, what
is the SpO2? Consider the possibility of tension pneumothorax.
 Circulation. In almost all patients with major trauma the cause of hypotension (low blood
pressure) is bleeding. If there is unexplained haemorrhagic shock, consider the possibility of
bleeding from pelvic or multiple bone fractures, into the pleural cavities or peritoneal cavity.
 After airway is checked, and Breathing and Circulation is not immediately life threatening, the
cervical spine must be stabilized, to avoid any potential spinal cord damages. Hold the top of the
patient’s head still and in line with the spine while a second person slides a semi-rigid neck collar
under the neck and then bends it to fit closely and comfortably beneath the patient’s chin.
Sandbags should then be placed alongside the head, and the head should be taped to the trolley
to minimise movement of the cervical spine. This safe and secure treatment is known as three-
point immobilisation.

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Figure 1. Three-point immobilisation

All trauma patients must be moved carefully in one coordinated movement,

keeping the spine straight, and with neck collar in place

 Continue the normal ABCDE assessment and management.

 Blood should be taken for full blood count, glucose, and cross matching as well as urea,
creatinine and electrolytes (if available).
 Chest and pelvic X-rays should be taken early but should not delay patient resuscitation. Unstable
or patients who might become unstable, should not be sent out of the emergency department to
have X-rays taken.
 FAST (focused assessment with sonography (ultrasound) for trauma) is a rapid ultrasound
examination performed at the bedside by the doctor that can support clinical management for
some cardiothoracic and abdominal injuries.

The way the injury happened

The circumstances of the injury, or the way the injury happened can give clues to the type and
seriousness of the injuries. It is helpful for diagnosis and treatment to try to estimate the amount of
energy transfer (the force that impacted the patient). Police or ambulance staff can give you a lot of
information about circumstances. Ask questions such as:
 -How did the injury happen, when and how many people were injured?
 The height of a fall or type of weapon used
 The speed and direction of impact
 The damage to passenger compartment of car and whether anyone else in the vehicle died
 Use of seatbelts
 Ejection from the vehicle
 Patient’s past medical history and any events leading to the trauma (e.g. loss of consciousness or
chest pain just before a motor vehicle crash).
Following an explosion even patients without external evidence of injury may have a severe blast
injury. In particular consider pneumothorax.

In Children
Children are more prone to:
 head and cervical spine injury
 pulmonary contusion, pneumothorax, desaturation
 intra-abdominal solid organ injury, bladder injury
 life threatening haemorrhage due to small circulating blood volume

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 Trauma

Chest injury

Liver Spleen

Figure 2. Be aware of possible liver and spleen injuries in patients with chest trauma, as both organs lie under the ribs. In a
patient with only chest injury, bleeding may occur from these organs in which case the blood will lie in the abdomen not the
chest cavity.

Signs and symptoms

 Pain at the site of injury
 Pain made worse by increased breathing
 Dyspnoea17
 Haemoptysis18
 Failure of the chest to expand normally – abnormal chest movements
 Cyanosis around the lips or fingernails
 Rapid, weak pulse and low blood pressure

Complications resulting from chest trauma

 All pneumothorax and haemothorax (see below)
 Laceration of the large blood vessels or liver and spleen
 Rib fractures
 Pulmonary contusion
 Blunt (not sharp) myocardial injury
 Pericardial tamponade (see below)

Pneumothorax / Haemothorax
Normally, the membranes (pleura) that line the lungs and chest cavity lie close together and slide over
each other., with negative pressure keeping the lung expanded toward the chest wall (see Respiratory
chapter). However, if for any reason that space between the pleura becomes filled with air
(pneumothorax) or blood (haemothorax), the lung can no longer expand fully and becomes partially or
totally collapsed. This can be caused by a chest injury (road accident, gunshot, blast), spontaneously
with or without underlying lung disease (tuberculosis, lung cancer), or due to medical care (post
surgery, puncture, drain).

17 Dyspnea: Difficult or laboured breathing

18 Haemoptysis = coughing up blood

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Tension Pneumothorax
We especially mention a tension pneumothorax because of the emergency treatment
needed for this type of pneumothorax. In this case the air trapped in the intrapleural cavity
increases rapidly which causes displacement (moving over) and compression (squeezing) of
the lung, the large blood vessels, the heart, and the lung on the opposite side of the injury,
as well.

Figure 3. Tension pneumothorax

This is a life-threatening emergency. Characterised by:

 Respiratory distress, tachycardia, hypotension, decreased breath sounds on only one side of the
chest
 Distended neck veins (figure 4)
 Cyanosis and tracheal deviation (shift of the trachea to the R or L side) are late signs

Figure 4. Distended neck veins

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If you suspect a tension pneumothorax, call a doctor for help immediately while also starting oxygen
therapy with a high concentration mask. The only way to save the patient in this emergency is
immediate decompression: insert a large (>16-gauge) intravenous cannula with needle into the 2nd
intercostal space, midclavicular, just above the third rib (Figure 5). The ability to easily aspirate air
confirms the diagnosis.

Figure 5. Needle thoracostomy. Insert a needle or cannula into the 2nd intercostal space in the mid-clavicular line. It may be
preferable to attach a saline-filled syringe and attempt to aspirate as the cannula is advanced. Bubbles will be seen in the saline
when the needle enters the pneumothorax.

A chest drain should be inserted routinely after needle decompression

Open Pneumothorax
This is a “sucking” chest wound. If the opening in the chest wall is more than 2/3 of the diameter of the
trachea, air passes through the opening in the chest wall rather than into the trachea, causing severe
breathing problems as well as the pneumothorax. Quickly close the chest wound with a sterile
occlusive dressing, large enough to overlap the wound’s edges and taped securely on 3 sides for a
flutter-type valve effect (Figure 6). As the patient breathes in, the dressing is sucked in over the
wound, so air cannot enter the chest cavity. When the patient exhales (breathes out), air is allowed to
escape through the open side of the dressing. The doctor will quickly place a chest drain in an area
away from the open wound.

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Figure 6. Place a sterile dressing over the wound and apply tape on three sides

Massive Haemothorax
Defined as >1500 ml of blood in the chest cavity. Clinical signs include no breath sounds and
haemorrhagic shock. Management consists of resuscitation (see Shock management chapter) while
the doctor also performs decompression of the chest cavity, using a large bore (>28F) chest drain.
Think about using an autotransfusion set when draining the haemothorax (see below).

Haemothorax with continuing loss of >200 ml of blood per hour should be a warning sign to call the
doctor.
Autotransfusion for haemothorax
Consider it if immediate blood loss through chest tube is
 500 ml for adults
 5 ml/kg for children.
Blood from the pleural cavity can be collected with a blood taking-set and bag, then immediately
transfused back to the patient (see Figure 7). It should not be done if the blood from the pleural space
is contaminated with bacteria, bile, urine or malignant cells.

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 Trauma

Figure 7. Auto-transfusion. Blood passes from the drain, through a Heimlich valve into a blood collecting bag before being
infused into the patient

Cardiac tamponade
Usually results from penetrating injuries (something sharp entering the body), but may follow blunt
cardiac trauma. Tamponade is the limiting or blocking of cardiac filling due to a collection of
fluid,(mainly blood in the case of trauma) between the heart and the lining surrounding it. Tamponade
results in shock and can lead to cardiac arrest. The fluid has to be removed, either by sucking it out
with a needle and syringe, or by surgical management. If the fluid is not removed, the heart will stop
beating.

Normal Cardiac tamponade

Fluid
Pericardium (blood)

Figure 8 Cardiac tamponade

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Diagnosis is often difficult and a cardiac ultrasound will confirm the diagnosis.
Classical clinical signs of tamponade are:
 Superficial neck vein distention (figure 4)
 Low blood pressure
 Tachycardia

Always consider cardiac tamponade when the jugular venous pressure is high and
blood pressure is low

Traumatic brain injury

Serious brain injury is difficult to manage outside specialised neurosurgical centres.
Most frequent causes of TBI (Traumatic Brain Injury) are road traffic accidents (RTA), falls from height,
gunshots and violent sports.

Based on the GCS (see Neurologic monitoring chapter) we can divide the patients into 3 categories.
 Minor Head Trauma: GCS of 13 to 15
 Moderate Head Trauma: GCS of 9 to 13, may lead to severe head injury over 48h
 Severe Head Trauma: GCS ≤ 8 (patients with GCS under 8 should be intubated if a specialized
neurosurgical center is available to refer the patient to.)
Brain injury can be divided into primary and secondary injury. Primary injury is the direct result of the
injury to the brain and is usually irreversible. Secondary injury is the damage to the brain tissue as a
result of seizures, raised intracranial pressure, shock, respiratory failure, hyper or hypoglycaemia. For
this reason it is important to achieve the targets in the table below. Good nursing and medical care
are vital to prevent secondary injury.

OBJECTIVES TARGET VALUES INTERVENTION

Normal oxygen saturation SpO2 > 94% Oxygen
Slightly raised blood pressure MAP 80-110 mmHg Vasopressors, fluids
(after control of extracranial
bleeding)
No Anemia Hb > 8g/dL Blood transfusion
No Fever T°C < 38°C Anti-pyretics (eg
paracetamol), fan
Normal blood sugar Blood glucose 80-120 mg/dL Insulin or Glucose
No hypernatremia Na+ 140-150 mmol/L Beware when giving 5%
glucose
Posture Sitting at 45 degrees, neck in
neutral position, avoid compression
of neck veins
Seizures Early detection and treatment Diazepam, midazolam,
sodium valproate
Table 1. Target values in patients with moderate to severe head trauma

Check hourly: HR, BP, RR, SpO2, temperature, blood glucose, GCS and pupils until instructed
otherwise.
Hb and sodium levels should be frequently monitored too. If any of these values are outside the
normal range, treatment must be given to correct the problem regarding of the medical prescription.

Pelvic injuries
Pain, tenderness when feeling with your hand or pelvic swelling suggests a diagnosis of pelvic
fracture. These fractures are important because of the possibility of massive blood loss from large
blood vessels in the area (Figure 9) and from the open surfaces of pelvic bones. Nearby organs and
soft tissues may also be injured, including urethra, bladder, rectum, vagina, perineum and nerve roots.

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 Trauma

Bladder

Pelvic ramus

Urethra

Rectum

Figure 9. Anatomy of the pelvis

NEVER insert a urinary catheter into a patient with suspected pelvic fracture

“Rocking” the pelvis by pressing down on iliac crests should not be used to examine the pelvis. It
risks dislodging formed clots and worsening fractures. If it is possible the patient has a pelvic fracture,
apply a pelvic binder as soon as possible. Look carefully for and firmly compress (press down on) any
active source of external haemorrhage.

Use a bed sheet as the pelvic binder (remove any clothing). The patient should be log rolled (see
Figure 12 in the Emergency assessement chapter) and the sheet placed underneath the patient. The
patient may then be log rolled onto the opposite side to pull the binder out the other side. The binder
should then be firmly secured, making sure that it sits at the level of the greater trochanters (Figure
10). Some recommend placing the binder higher (Figure 10), which may make it more effective in
reducing bleeding, but makes it more difficult to get to the lower abdomen and upper pelvis to perform
surgery.

Figure 10. Pelvic binder at the level of greater trochanters (left) and at the level of iliac crests (right)

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A pelvic binder provides temporary stabilisation (keeps the area still) only; it does not reduce or re-
align the fractures. If patient is haemodynamically unstable, complete stabilisation with bilateral (both
sides) external (outside) fixation should be performed as soon as possible.

Limb injuries
If there is major arterial bleeding from a limb, the limb should be raised and pressure should be
applied for at least 10 minutes, using one finger and gauze pressed directly on the bleeding vessel,
just above the bleeding point.
To apply a pressure bandage, a dental roll or tightly folded gauze should be applied accurately over or
just proximal to (above) the bleeding point. Once position is correct and there is no further bleeding,
larger or less folded pieces of gauze can be applied to form an inverted pyramid, which should then
be secured with a bandage.

If manual pressure is unsuccessful in controlling arterial bleeding, a tourniquet (something that can be
used to apply pressure) may be applied as a temporary measure until the artery can be more
permanently repaired.
To apply a tourniquet: place a blood pressure cuff proximal to the bleeding point and inflate it to above
systolic blood pressure. If a blood pressure cuff is not available, the tourniquet used should be wide
and applied tightly enough to cause arterial (not just venous) compression. The time of application
and neurological status (movement, sensation) of the limb should be recorded. A tourniquet should
not be left on for more than 120 minutes and should only be removed by the surgeon in the operating
theatre.

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Burns
Pathophysiology
Local effects
Thermal, electrical and chemical burns immediately destroy tissues in the skin. Very deep burns can
also damage tissues below the skin such as muscle or bone. All burns cause inflammation which
causes the damaged blood vessels to dilate and leak plasma and fluid. This results in oedema (a
collection of fluid in the tissues) in the burned area and nearby tissues.

General effects
Burns over a large area also cause a generalized inflammatory reaction in non-burnt body tissues and
vital organs. This causes hypovolaemia, generalised oedema and loss of water and sodium.
Movement of fluid from the blood vessels into the tissues mostly happens in the first 8 to 12 hours, but
further movement happens up to 36 hours after the burn.
The total amount of oedema depends on how serious the burn is and the extent of the resuscitation. If
not enough fluid is given, the patient can get hypovolaemic shock and organ hypoperfusion. However,
giving too much fluid will produce excessive oedema.
24 hours after the burn, leakage of fluid from the blood vessels decreases, oedema formation slows
down and fluid starts to return back into the blood vessels. Renal elimination of excess water and
sodium occurs from 36 hours after the burn onwards.The patient’s urine output can increase as the
kidneys get rid of the extra water and sodium. Regarding vital organ function, there are 2 phases in a
major burn injury:
 Initial fluid phase over first 24 to 48 hours
 Secondary metabolic phase starting at 36 to 48 hours post-burn

Effect on vital organs

Burns of over 15% TBSA (total body surface area) cause significant effects on multiple organ systems
in adults and children >1 year. The effects are roughly in proportion to the extent of the burn.

In children
<1 year old, burns of over 10% will cause significant effects on multiple organ systems.
Respiratory effects
Even without a direct inhalational injury, respiration is often affected in the early stages. Desaturation
and the extra work needed for breathing can be due to secondary lung injury because of the burns,
mechanical restriction of breathing (extensive chest or neck burns) or large amount of fluid that has
been given to resuscitate the patient.
Metabolic effects
From around 48 hours onwards, the body is in a hyper metabolic state (needing a lot of energy) in
order to heal the burns. More energy is used due to wound evaporation heat loss, pain, fear and
anxiety.
Immunological effects
Major burns induce immunosuppression that makes the patient more likely to get an infection.
Observing the patient closely is important (refer to Severe sepsis part in the shock chapter)
However, a physiological fever < 38,5°C, due to hyper-metabolism (high amount of energy being
used) is normal.
Electrolytes
Burn injuries alter water and electrolyte balance.
Hyponatraemia (low sodium concentration) and hyperkalaemia (high potassium concentration) are
common in the Initial fluid phase. If plasma sodium is increased (> 155 mmol/l) in this phase, it is often
a sign of inadequate fluid resuscitation.
Hypernatraemia (high sodium concentration) and reduced plasma concentrations of potassium,
magnesium and phosphate are commonly seen in the metabolic phase.

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Management
Important critical care issues include:
 Primary survey (as burned patients can also be crushed, have blunt injuries, be traumatized) and
initial resuscitation, including giving analgesia
 Secondary survey, evaluation of TBSA (total body surface area) and exclusion of associated
traumatic injuries
 Supportive management.

Primary Survey
As for any trauma patient, an initial assessment should be done, checking the airway, breathing,
circulation and amount of disability (refer to Initial assessment chapter). The burn injury must not
detract from the standard ABC approach because associated injuries are common and can be missed.
Burns can occur as a result of explosions and road traffic accidents. Falls after electrocution are
common.
Airway
The airway should be carefully assessed. Airway obstruction can be caused by extensive neck or
facial burns, or airway oedema from a direct airway burn or as part of generalised oedema. Burn
oedema progresses over time, especially over the first 6 hours and with on going fluid resuscitation.
So any patient that arrives at the hospital is at risk of developing airwayobstruction after admission.
This can be a particular problem in young children. If there is any doubt about airway patency, or if
there are burns around the neck, an anaesthetist should be consulted and early tracheostomy should
be considered.
Breathing
Burn injuries can cause difficulties with breathing due to:
 Smoke inhalation. Especially think about inhalation burns if the face is burnt and black
saliva is seen around the lips and in the mouth and nose
 Toxic gas poisoning
 Mechanical restriction from extensive chest burns. Pulmonary injury secondary to blast
phenomenon should be considered if there has been an explosion.
All major burns should receive high-flow oxygen; ideally 10L humidified O2 with a high concentration
mask for 24 hours
Suspect an inhalational injury if victim was burnt in an enclosed area and/or has at least one of the
following:
 Facial and neck burns
 Soot in upper airway or black sputum
 Wheezing, hoarse voice
 Burned hair in the nose
 Crackles or unexplained headache
 Neurological signs.
If inhalation burns are suspected, treatment should include:
 Oxygen +++
 Inhaled salbutamol every 4 hours
 Frequent chest physiotherapy
 Turn patient on their side every 2 hours

Circulation
Hypotension and shock early on are rarely due to the burn injury alone. If the patient is hypotensive
and there was no delay in them getting to hospital, exclude other causes such as cardiac dysfunction,
pneumothorax, internal bleeding and spinal cord injury.
After obtaining IV or IO (intra-osseous) access, preferably in non-burned tissue, start fluid
resuscitation with crystalloid according to Parkland formula (see below).

Always start fluids (Ringer’s lactate) even before calculating TBSA and Parkland
formula

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Disability
If the patient has decreased consciousness, look for a cause. It is not due to the burn itself. Causes
include desaturation, toxic gas inhalation, hypovolaemia, seizure, substance abuse or associated
head injury and any underlying pathology (ie malaria).
Major burns cause intense pain. Patients should receive adequate pain killers. Opiods will often be
necessary, so special attention should be paid to the patient’s respiratory rate (see Pain Management
chapter)

Carbon monoxide poisoning should be suspected in anyone who lost

consciousness in a fire

Analgesia
Burns cause extreme pain, which usually require large doses of powerful opiates, ideally given by
intravenous infusion. Subcutaneous and intramuscular routes may be unreliable due to variable
absorption (ei.tissue damage). However intravenous infusion is dangerous if the patient cannot be
constantly monitored in a safe environment with appropriately trained staff (refer to Pain management
chapter)

Secondary survey
Carry out a secondary survey as soon as the patient has been stabilised. A thorough history should
include details of what caused the burn, circumstances and time of injury:
 If the fire occurred in a closed space (high risk of inhalation injuries).
 Whether there was an explosion or fall (risk of other trauma).
 If any treatment has already been carried out
 Time of injury and how much time has passed before admission.
The patient should be undressed (only remove clothing not sticking to burn) and carefully examined
head-to-toe to calculate burn area and exclude additional traumatic injuries. Wear a mask and sterile
gloves to perform the examination because reducing nosocomial (hospital acquired) infection is a
priority right from the start (see infection control chapter)

If there is any suggestion of trauma, the patient should be assessed, investigated

and treated in a similar manner to a trauma victim, while treating the patient for
burns at the same time

Burn patients easily become hypothermic. Once the examination is completed, cover and warm them.
A sterile sheet should be used to cover the burnt areas until occlusive burn dressings are in place.
Routine investigations are Hb, glucose, blood group, and dipstick urine analysis; if available,
electrolytes, blood gases and renal function. X-rays may be needed if associated trauma is suspected,
however do not send a burns patient with a possible airway obstruction or who is unable to protect his
airway to the radiology department.

Extent of burn injury

Assessing the area of burn is important, as it directly affects the fluid resuscitation, nutritional needs
and prognosis. The most accurate method of assessing the burn area is to use the Lund and Browder
chart (see below). This chart takes into account the age-related changes in body proportions. Count all
burn wounds of 2nd degree and higher. Dark-skinned patients can be difficult to assess.

Re-evaluation of total body surface area (TBSA) burned is often necessary after the first burn dressing
when dead epidermis is removed.

Carefully check if there are eye burns or circumferential (all the way round) burns of limbs, thorax or
neck because these may require special treatment.

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Do not attempt to evaluate burn depth at this time. Burns are a mixture of different depths and will
change over time. Delayed or inadequate treatment and infection can worsen burn depth. The
difference between superficial and deep burns does not become clear before 10 days at the earliest.
Age (years)
Site
<1 1–4 5–9 10 – 15 Adult

Head (front) 9.5 8.5 6.5 5 3.5

Head (back) 9.5 8.5 6.5 5 3.5

Neck (front) 1 1 1 1 1

Neck (back) 1 1 1 1 1

Torso (anterior) 13 13 13 13 13

Torso (posterior) 13 13 13 13 13

Buttock (left) 2.5 2.5 2.5 2.5 2.5

Buttock (right) 2.5 2.5 2.5 2.5 2.5

Perineum 1 1 1 1 1

Upper arm (left) 4 4 4 4 4

Upper arm (right) 4 4 4 4 4

Forearm (left) 3 3 3 3 3

Forearm (right) 3 3 3 3 3

Hand (left) 2.5 2.5 2.5 2.5 2.5

Hand (right) 2.5 2.5 2.5 2.5 2.5

Thigh (left) 5.5 6.5 8.5 8.5 9.5

Thigh right) 5.5 6.5 8.5 8.5 9.5

Lower leg (left) 5 5 5.5 6 7

Lower leg (left) 5 5 5.5 6 7

Foot (left) 3.5 3.5 3.5 3.5 3.5

Foot (right) 3.5 3.5 3.5 3.5 3.5

Table 1. Lund-Browder chart of body surface area, according to age

Severe burn:
 When BSA > 15% in patient > 1 year old
 When BSA > 10% in patient < 1 year old

If age (in years) + BSA burnt (in %) is > 100, the outcome is very poor.Those patients meeting these
criteria should either be transferred to a specialist burns unit (often not possible) or thought should be
given to providing palliative care (end of life) only (refer to Palliative cares chapter).

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Fluid therapy
Early fluid resuscitation needed as a result of fluid shifts and losses is a key part of major burn care in
the first 24 hours. This should be given to all patients over 1 year with burns ≥ 15% TBSA and all
infants under 1 with burns ≥10% TBSA. The aim is to maintain the fluid balance and keep enough
blood supply to the organs while minimising the risk of worsening oedema. Too much fluid increases
the risk of circulatory overload, pulmonary and cerebral oedema and compartment syndromes19 in
burned and non-burned zones.

First 24 hours
The Parkland formula is used to calculate how much fluid is needed over the first 24 hours. It gives the
volume (in mL) of Ringers lactate that should be given.

Volume (mL) = 4 x body weight (kg) x % TBSA burnt

Half of this volume should be given in the first 8 hours from the time of burn (not the time the patient is
seen). Fluid already given before calculating the fluid requirement should be taken away from this first
volume.

The second half of the volume should be given over the following 16 hours.
For inhalation injuries and high-voltage electrical burns, increase the fluid volume calculated by 50% =
6 x body weight x TBSA burnt.

Example: A patient with a weight of 50kg arrives with 20% of TBSA burns

4 x 50 x 20 = 4000 ml

So 1000ml needs to be given in 8 hours => 250 ml/h (flow rate 42 drop/min)
And the other 1000ml will be given in 16h => 125 ml/h (flow rate 21 drop/min)

In children
Children under 12 years old if not allowed or able to drink and eat, need daily maintenance fluids as
well as Parkland resuscitation fluid volume.
Maintenance fluid should be given as Ringer’s lactate, alternating with 5% glucose.

Giving fluid is only a starting point and that fluid treatment should be changed according to the
patient’s physical state. The most useful measurements are MAP (mean arterial blood pressure) and
urine output. A urinary catheter should be inserted for all patients with major burns to accurately
monitor urine output.

After 24 hours
At this stage, it is usually enough to give only maintenance fluids in both adults and children. Fluids
are given as a combination of intravenous Ringer lactate and 5% glucose, and orall fluids (eg. soup,
milk, juice, enteral feed).

Rhabdomyolysis
Rhabdomyolysis is the destruction of muscle cells.
Some burn patients are at risk of extensive muscle damage, which releases Hb, myoglobin and
potassium into the circulation. Myoglobin (or Hb) excreted in the urine shows up as a reddish, dark
brown or black colour and positive haem test (blood) on a dipstick. This should be reported to the
doctor as the patient may need larger volumes of fluid and a higher urine output should be aimed for.

Escharotomy
Circumferential or nearly circumferential deep burns cause the skin to lose its normal elasticity. Burn
wounds and generalized oedema in underlying tissues then lead to rising tissue pressures. In the

19Compartment syndrome = a condition resulting from increased pressure within a body space that
cannot expand easily.

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limbs, this phenomenon can reduce blood flow to the hands and feet, progressing to necrosis (death
of tissue due to loss of blood supply) if not relieved.
Capillary refill and tense swelling of the limbs at risk should be checked regularly.

In the case of extensive trunk (central part of body) burns, breathing can be made difficult by a rigid
chest wall or high intra-abdominal pressure.
If the skin on the limb becomes very tight or there are signs of poor perfusion, or if breathing is
compromised, escharotomies should be urgently performed under general anaesthesia. It’s a surgical
treatment. Burnt tissue (eschar) is divided until excessive pressure is relieved.

Figure 1. Escharotomies involve incising through burn wound and fascia along the lines shown above

Tetanus
Burn patients have a high risk of tetanus and tetanus prophylaxis has to be started.

Nutrition
Severely burnt patients need high amounts of calories and protein. Children and young adults may
use twice the amount of energy they usually need. Failure to meet these increased requirements
result in malnutrition, muscle wasting, poor wound healing and decreased resistance to infection.
Oral nutritional supplement or nasogastric tube + enteral feeding (see Nutrition chapter)

In children
Children can become (more) malnourished very quickly. Oral intake is difficult in younger children
because of pain, anxiety and inability to understand the importance of adequate oral intake. Frequent
small feeds and giving extra high calorie biscuits or paste may help.

Control of infection
(Refer to Infection control chapter)
Skin is a natural protector against bacterial contamination. For burn patients, this first protection
disappears. The patient is extremely vulnerable to infection.

Local burn treatment

The aim of local burn treatment is to limit secondary infection, encourage healing, reduce pain,
prevent contractures (abnormal shortening of muscle tissue) and limit reduction in function and
disfigurement.

Burn dressings should be occlusive (water and air tight), analgesic (pain killing), allow mobilisation of
the patient and avoid heat loss.

Basic rules
 Strict aseptic technique.
 Dressing changes require strong and effective pain control.
 In the case of extensive burns, the first dressing is done in the operating theatre under general
anaesthesia.

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 Urinary catheter is needed for all patients with perineal and/or upper leg burns. Urine should be
tested for signs of infection using a urinary dipstick.
Dressing should be changed every 48 hours but daily dressing changes are needed for perineal,
soiled burns and infected burns.
The dressing change has to be planned:
 Explain to the patient and his family
 Prepare the room and all the equipment needed
 Prepare the analgesia plan following the protocol or the anaesthetist prescription (Nitrogen
Monoxide and/or give painkiller before dressings are done making sure they will still be effective
during the dressing change
 When dressing hands, the hand has to be in a specific position to reduce the risk of mobilization
disability
 Physiotherapy has to be started as soon as possible to reduce the risk of any disabilities post burn
(first day if possible)”

Other treatment
Skin grafts can also be part of the treatment

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Obstetric care

Management involves the whole team (obstetrician, anaesthetist and midwife)

giving high quality and effective care

Pre-Eclampsia and Eclampsia

 Normally blood pressure slightly decreases during pregnancy. In a pregnant woman, hypertension
is defined as BP > 140/90 mmHg.
 Chronic hypertension is defined as hypertension the patient had before pregnancy or appearing
before 20 weeks LMP.
 Hypertension brought on by pregnancy is defined as isolated hypertension without proteinuria
(protein in the urine), that appears after 20 LMP.

Diagnosis
In any ill pregnant woman, always think about the possibility of pre-eclampsia, take the blood pressure
and check for proteinuria. BP has to be checked several times, with the woman seated and at rest.
Pre eclampsia is defined by the association of :
 high blood pressure (> 140 / 90 mmHg) AND
 proteinuria (more > 1+ on urine dipstick) in a pregnant woman who’s last menstrual period (LMP)
was at least 20 weeks ago, and until 7 days after delivery.
Pre eclampsia is a complicated disease, affecting many organs, including heart, liver and kidneys. It
has a significant risk of complications :
 for the foetus (limited foetal growth , foetal distress, foetal death, )
 or / and for the mother by the way of
 > various organ failure and / or
 > obstetric complications such as placental abruption, eclampsia, HELLP (= haemolysis,
elevated liver enzymes and low platelets), all of them may be life threatening for both mother
and baby.
Severe pre-eclampsia is defined by one or more of the following signs:
 Systolic BP ≥ 160 mmHg or/ and diastolic BP ≥ 110 mmHg.
 Proteinuria ≥ 3+ on dipstick test or more than 5g/day
 Low urine output < 400 ml/day or 30 ml/hour
 Hyper reflexia
 Epigastric pain, nausea, vomiting,
 Pulmonary edema
 Intense headache not relieved by paracetamol
 Buzzing in the ears or visual disturbances
Eclampsia is defined by convulsions in the third trimester of pregnancy, usually in a context of pre-
eclampsia. It can occur until 48 hours after delivery. Always consider other causes of convulsions as
well (such as malaria, meningitis…)

When possible:
 measure Hb,
 determine blood group
 analyze platelets, liver enzymes and renal function to assess severity of the disease.

Management of severe pre eclampsia

The best treatment of any pre-eclampsia or eclampsia is delivery of the foetus and placenta. However,
the risk to mother and foetus from pre-eclampsia needs to be balanced against the risk to foetus from
an early delivery. The patient should be moved to a place with obstetric and neonatal support.
Midwives, obstetricians, paediatricians and nurses should all work closely together.

From a critical care point of view, the important parts of management are:
 Fast delivery of foetus.
 Prevention of seizure
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 Blood-pressure control
 Prevention of complications
For severe pre-eclampsia, fast delivery is essential.
 Delivery is absolutely necessary within the first 24 hours of onset (either vaginally or by caesarian
section)
 A magnesium sulfate loading dose should be given followed by maintenance doses according to
normal procedure.
Treatment (Magnesium Sulfate) has to be maintained for 24 hours after delivery.

Magnesium is only excreted by the kidneys. Pre-or eclamptic patients often suffer from renal damage
and have an increased risk of magnesium overdose so should be closely monitored.

In the 1st hour, monitor patellar reflex, blood pressure, pulse and respiratory rate every 15 minutes.
Then, if there are no signs of magnesium overdose, continue monitoring vital signs + urine output (by
urinary catheter) every hour.

Magnesium overdose Mild Moderate Severe

Neurological symptoms Slower reflexes, No reflexes, sleepiness, Muscle paralysis
headache general muscle weakness
Cardiovascular symptoms Flushing Hypotension, bradycardia Cardiac arrest

Respiratory symptoms Slow respiratory rate RR < 12/min Respiratory

with RR < 15/min paralysis
Digestive symptoms Nausea

If urine output is < 30 ml/hour or < 100 ml/4 hours, stop magnesium infusion, and closely monitor the
patient.
If there are any signs of moderate magnesium overdose (disappearance of patellar reflex, RR <
12/minute…) stop magnesium infusion, and closely monitor the patient every 15 minutes, looking for
any worsening signs.

If there are any signs of severe magnesium overdose, stop magnesium infusion,
and give calcium gluconate (10%) 10 ml slow IV

Anti hypertensive treatment

Used to prevent maternal complications while at the same time ensuring adequate placental perfusion.
Need to be started if systolic BP is ≥ 160 mmHg or diastolic ≥ 110 mmHg .
Give oral drugs if possible (labetalol or methyldopa).
If the oral route is impossible or maternal condition is very severe, use injectable labetalol or
hydralazine. These IV drugs have the advantage of rapid onset, reliable drug delivery and possible
adjustment of drug dosage against the mother’s blood pressure fall.
Note that if the mother receives labetalol, you will have to keep the neonate in observation for 72
hours at least after the birth because of the risk of bradycardia, hypoglycaemia, and respiratory
distress.
When administering, closely monitor the mother’s BP and pulse, and the foetal heart rate. The dose
should be adjusted according to changes in BP. Hypertension is controlled when diastolic is between
90 and 100 mmHg and systolic between 130 and 150 mmHg.

Administering too high a dose of anti hypertensive or giving it too quickly can lead
to an excessive fall in maternal BP, with potential foetal death”

Diastolic BP should not go below 90 mmHg. If the blood pressure goes too low, Ringer’s lactate
should be given to restore it ≥90 mmHg.

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General measures
The patient should lie in the left lateral position to prevent supine hypotension syndrome” due to
compression of IVC and aorta by uterus (Figure 1)

Figure 1. Relief of aorto-caval compression in lateral position

 If this is not possible, then displace the uterus laterally (Figure 2).

Figure 2. Lateral displacement of uterus

Regular monitoring of: pulse, blood pressure, oxygen saturation, respiratory rate, urine output, mental
status, reflex and neurological disturbances, obstetrical monitoring (foetal heart rate, vaginal
examination).

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Management of eclampsia.
 Call for help
 Protect against injury, falls
 Maintain open airway (simple manoeuvres and artificial airways)
 Place in left recovery position
 Insert an IV line
 Treat seizures with Magnesium sulphate (as indicated for severe pre eclampsia above). Continue
treatment for 24hours after delivery or after the last seizure (whichever occurred last). Be sure to
have calcium gluconate ready if needed.
 Give oxygen to get a SaO2 > 94%
 If systolic BP is ≥ 160 mmHg or diastolic ≥ 110 mmHg : labetalol or hydralazine IV (as for severe
pre-eclampsia)
 Delivery must be done within 12 hours, either vaginally or by caesarian section :
 Closely monitor and record BP, pulse, SaO2, respiratory rate, mental status (AVPU), urine output,
temperature and patellar reflex. Always look for signs of Magnesium overload.

Post partum haemorrhage (PPH)

The post partum haemorrhage (PPH) is defined by blood loss of more than 500ml, during the 24h
following the delivery for early PPH, and between 24 hours to 6 weeks for late PPH.

PPH can be rapid and severe, which can lead to hypovolaemic (haemhorragic) shock and death. Fast
identification of the cause and treatment is necessary.

It is not always easy to see how much blood is lost as blood is mixed with amniotic fluid. It is useful to
use a collection bag placed under the patient or make a note of how often protective pads have to be
changed.

Note that compensatory mechanisms are very efficient in young women so clinical signs of bleeding
may not be obvious at first Therefore it is essential to monitor post partum patients closely to detect
any complications, especially haemorrhage.

Management
The most important point for PPH management is advance screening and coordination between
members of the multidisciplinary care team. Midwifes, nurses, obstetricians and anaesthesiologists
have to be well informed, act quickly and efficient.

Close monitoring of the immediate post partum period is essential

 Call for help

 Standard haemorrhage shock management (refer to Shock chapter)
 Empty bladder is needed to give enough space for uterine contraction (always put in a urinary
catheter)
 Remove blood clots
 Find out the cause. A systematic assessment of uterus and birth canal has to be done by the
midwife or gynaecologist.
 Monitor and assess severity (vitals, Hb, urine output, bleeding from the vagina) and record all in
the PPH form (note time PPH began)
 Medication (refer to PPH protocol in appendix 3)
Initial measures to stop bleeding
 Uterine massage to help remove clots and start uterine contraction (do this continuously at the
beginning of the PPH). First check the bladder is empty (insert a urinary catheter).
 Administer a uterotonic (a drug that starts uterine contractions) : oxytocin loading by slow IV
injection, and at the same time, start an infusion of maintenance oxytocin
 If no effect within 15 minutes, give misoprostol and / or methylergometrine (contra indicated in a
case of pre- or eclamptic patient)
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 Consider blood transfusion quickly

Meanwhile, the midwife or obstetrician will

 Make sure the uterus is empty by removing the placenta if not yet delivered, and/or manually
checking the uterus and birth canal
 Insert an intra uterine compression balloon (Bakri balloon) and monitor bleeding inside the bag.
 Do a bi-manual uterine compression if Bakri balloon unavailable or ineffective
 Consider laparotomy and hysterectomy for haemostasis (stopping of bleeding)
Post procedural care
 Continue to monitor pulse, blood pressure, oxygen saturation, urine output, haemoglobin, uterine
tone, vaginal loss.
 Look for complications of transfusion or surgery (refer to Blood transfusion and Post surgery care
chapter).
 Keep patient warm and use warm intravenous fluid. Coagulation is impaired by hypothermia
 Provide adequate analgesia (pain killers).
 Re-assess the patient.

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Post-operative care
The aim of this chapter is to provide the tools needed to anticipate and detect problems that can
happen after surgery and the basic management of major complications.

Post Anaesthesia Care Unit (PACU)

The objective of care in the PACU is to prevent, detect and treat any postoperative complications
related to either anaesthesia or surgery (e.g bleeding, neurological deficit or airway compromise). Any
patient who receives a surgical procedure with any type of anaesthesia (except local anaesthesia),
needs to pass through the PACU before being admitted to the ward. An effective PACU is one of the
most powerful tools for reduction of perioperative morbidity and mortality.

Equipment
Deterioration of the patient status in the PACU can be very sudden and needs prompt action.
Appropriate and functional equipment can save lives. Before the patient arrives, the nurse in charge
must ensure that all necessary emergency and monitoring equipment is available and working.
Respiratory
 Oxygen supply with flow meter. Oxygen delivery device (nasal prongs, mask or high
concentration mask) connected
 Ambu bag with filter and mask connected
 Oropharyngeal airway (Guedel)
 Mechanical or electrical suction with suction tube
 Intubation equipment (laryngoscope handle and blade, endotracheal tube, tape, syringe).
Monitoring for each bed
 Monitor with SpO2 and alarm checked and activated
Monitoring for the room
 Glucometer, HemoCue, thermometer, blood pressure cuff and sphygmomanometer
 Stethoscope
 Automatic External Defibrillator (AED) tested and plugged in (if available)
Infusion equipment
 Syringe pump
 IV catheter and equipment required for IV administration
Drugs
 Epinephrine, dopamine, ephedrine, atropine, neosynephrine (phenylephrine), prostigmine,
naloxone
 Pain killers (analgesics)
 Fluids (Ringers lactate, normal saline, 5% glucose)
Warm blanket

Patient management and immediate post operative

complications
A thorough assessment including the original problem, the surgical procedure, the current physical
assessment findings and the ongoing management should be recorded legibly in the patient file. It is
important that evaluation of the patient continues until discharge to the ward, with frequency of
observations, dependant on severity of illness and surgical procedure or changes in patient condition.
Critically ill patients and those at risk of deterioration require frequent and sometimes continuous
assessment. Additional observation is necessary when acute new problems present, and should
always be reported to the doctor.

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When the patient arrives in PACU

 Transfer the patient to the bed and help them into a comfortable position, according the surgery
performed and any medical orders to keep them in a specific position
 Hand over is essential. The nurse in charge receives hand over from the anaesthetist
 Properly identify the patient
 Problems linked to the patient
 E.g. pre-existing disease such as chronic hypertension
 Problems linked to the surgery
 What surgery has been performed?
 What are the specific post operative risks?
 Problems linked to anaesthesia (was there a specific peri-operative problem)
 E.g. recurrent hypotension during a spinal anaesthesia
 Type of anaesthesia drugs
 Pain killers given
 Post operative management
 General: focused on the main functions (respiratory, hemodynamic, neurologic)
 Specific: according to the patient, the surgery and the anesthesia
Assessment (A B C D E)
 Take vital signs
 HR, BP, RR, SpO2, temperature, urine output/void, Pain evaluation
 Mental status: AVPU
 Evaluation of sedation and respiratory status (Table 1.)
 Thoroughly check the patient’s body for any abnormal clinical signs (colour, warmth, rashes)
 Check for any major bleeding (dressings and drains) and note the amount
 Assess perfusion of operated limbs (capillary refill time, colour, pulse, warmth, pain)
 Check the recorded intake and output (infusions, urine, drains, ostomies/stomas)

Sedation score Respiratory score

S0 Awake R0 Regular respiration, no breathing
difficulty and RR ≥ 10/min
S1 Intermittently drowsy, easily awakened R1 Snoring and RR ≥ 10/min

S2 Drowsy most of the time, responds to R2 Irregular respiration, obstruction,

voice chest indrawing, RR < 10/min
S3 Drowsy most of the time, responds only R3 Respiratory pauses, apnoeas
to physical stimulation
Table 1. Sedation and respiratory scores

Medical prescription
 Check medications prescribed and plan the next due doses (don’t forget the fluid rate)
 Prophylactic strategies (thromboprophylaxis, antibiotics, pain management)

Close monitoring and assessment are important to identify changes in

physiological parameters. Look at the progression, not just the absolute numbers!
Identifying worsening trends help to detect deterioration BEFORE severe organ
dysfunction or failure occurs.

Monitoring
Monitoring is more frequent in the initial state and varies depending on the stability and risk of
deterioration. Vital signs should be recorded every 5-10 minutes for the first hour.
The time the patient first passes urine, as well as the quantity and appearance of the urine, should be
noted for non-catheterised patients.

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For spinal anaesthesia

Check for any signs of urinary retention. Some patients are at risk of post-operative urinary retention:
elderly, male, pre-existing neurological disease, ano-rectal or hernia surgery, long surgery, excess
fluids.
Patients with risk factors who are unable to pass urine within 4 hours post-op should be examined.
Patients without risk factors should normally be able to pass urine by themselves within 8hrs.

When monitoring, it is important to document specific values and to know

abnormal limits, (eg: oliguria for 2hrs if catheterised) which should prompt the
nurse to ask for medical evaluation.

Immediate complications
Complications may occur that are related to the anaesthesia, the surgical procedure or underlying
health conditions.
 Anesthaesia drugs:
 Respiratory depression
 Nausea and vomiting post surgery
 Surgical procedure:
 Haemorrhage
 Pain
 Hypothermia
 Infection
 Underlying health conditions:
 Acute decompensation of chronic illness
The following possible complications are listed in order of importance:
Airway obstruction
Causes:
 Incomplete elimination of anaesthetic drugs (hypnotics, muscle relaxants, opioids) can lead to
airway obstruction.
 If the patient is not fully awake when extubated, the tone of the pharyngeal muscles won’t be
enough to keep upper airway open.
 Anaesthetic drugs like Ketamine increase saliva and bronchial secretion that can lead to airway
obstruction.
Airway obstruction must be managed immediately. Treatment can involve:
 Verbal or painful stimulation to wake the patient up
 Antidotes according to anaesthesia provided
 Otherwise standard management of airway obstruction (see Emergency assessment chapter), in
particular consider whether suction may help
Respiratory depression
Opioid drugs such as fentanyl can cause respiratory depression if too much is given. The patient will
first show signs of increased sedation and decreased respiratory rate, and this can progress to full
respiratory arrest if not noticed and treated early with Naloxone (refer to pain management chapter).
Onset of excessive drowsiness indicates an overdose and often occurs before bradypnoea
(abnormally slow RR < 8 rpm). Because drowsiness is an early warning sign, it must be regularly
evaluated using the sedation scale (Table 1.)
Hypotension
Causes
 Anaesthetic drugs (vasodilatation)
 Spinal anaesthesia
 Blood loss, Haemorrhage
 Shock (anaphylactic, septic, cardiogenic, hypovolemic)

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Management
 Take vital signs, check clinical status, compare with previous signs
 Check for signs of bleeding, either new bleeding or an increase in bleeding (drains, etc)
 Inform doctor
Haemorrhage
Hypovolemia can occur due to blood loss. This loss can be seen externally by the drainage or
bleeding on the dressings. It can also be internal (secondary to surgical complications) and more
difficult to detect.

Beware that signs of hypovolaemia are not detectable until the patient has lost 10-15% of their blood
volume.
How to detect and monitor haemorrhage?
Vitals signs (tachycardia always occurs first)
Monitor all drains for excess blood loss hourly
Check surgical dressings
Colour of patient (conjunctiva, mucosa, palm of the hand)
Check the haemoglobin with a HemoCue. Note that the trend is important and this value will only fall
at a late stage.

Refer to Haemorrhagic shock and blood transfusion chapters for advice on management

If increased bleeding is seen on the dressing, the surgeon must be called. The
dressing should not be opened/removed unless the surgeon is present and
requests this. If needed, reinforce the dressing until the surgeon arrives.

Postoperative alteration in mental status

Postoperative changes in mental status include failure to recover consciousness, responsiveness, or
baseline mental status within the expected time frame following general anaesthesia.

Causes may include:

 Delayed elimination of anesthesia drugs (due to renal impairment)
 Overdose of drugs
 Use of ketamine peri-operatively (risk of hallucinations)
 Hypothermia
 Pain
 Urinary retention (especially in the elderly)
 Hypo or hyperglycaemia
 Recent use of, or withdrawal from, alcohol or other drugs

Risk
 If unresponsive: loss of protective airway reflexes with risk of aspiration
 If confused and agitated: Self-inflicted injury and removal of drains or IV lines

Management
 Clinical observation (agitation, restlessness, confusion, drowsiness, uncooperative behaviour, etc),
 Check vital signs (including blood sugar)
 Compare with previous neurological status, check if anaesthetic agents (opioids, hypnotics) were
given recently
 Call the doctor
 Ensure adequate oxygenation (mild desaturation can cause restlessness
 Stimulate the patient if drowsy (use verbal or tactile stimuli)
 Restrain the restless and confused patient to prevent injury to self and staff

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Pain
Refer to acute pain management chapter

Hypothermia
Defined as axillary temperature < 36°C
Hypothermia is a common result of anaesthetic drugs (vasodilatation and shift of body components),
fluids (skin preparation fluids, irrigation fluids, IV fluids), surgical procedure (exposure of organs to the
air) and cool temperature of the operating room.
Effects of hypothermia
 Reduced effect of pain medication and antibiotics, possible increased duration of anaesthetic
drugs
 Vasoconstriction
 Increased bleeding risk
 Increased risk of infection
 Shivering and discomfort for the patient
Prevention
 Cover the patient
 Use warming blankets (+/- warm air blanket)
 Warm IV fluids and blood products for transfusion
 Stop air conditioning in the room if needed

Hypothermia pre and post surgery increases length of hospital stay, risk of
complications such as bleeding and infection, as well as mortality rates.

Post-operative nausea and vomiting (PONV)

PONV is one of the most frequent complications in the early post-operative period. It is due to
anaesthetic drugs, pain killers (opioids) and pain itself.

What to do?
 Make sure that the patient is in a position that reduces the chance of aspiration (sitting upright)
and that suction equipment is available.
 Maintain functional IV lines and make sure there are medications prescribed for prophylaxis
and/or rescue therapy, if not ask the doctor (e.g. anti-emetics: Ondensetron, Dexamethasone,
Haloperidol, Promethazine)

Pain killers (especially opioids) can increase the risk of PONV, but should not be
interrupted if the patient is in pain. Anti-emetics should be added.

Acute decompensation of chronic illness

In any patient has an underlying chronic disease, that disease can decompensate (get severely
worse) in the post-operative period. This is due to extra stress placed on the body from surgery and
from the condition that required the surgery.

PACU Discharge Criteria

Postoperative patients can be discharged to the ward when the following conditions are met:
 Awake, alert, calm and orientated
 Patient has an adequate cough, RR <20/min, and can maintain SpO2 >95% on either no oxygen
or low level oxygen therapy of < 3L/min
 Patient is hemodynamically stable, SBP 90-150 mmHg and HR < 120

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 Warm peripheries, no active bleeding in drains or close to preoperative measurements (if drains
were present pre-operatively)
 Clean dressing
 Urinary output > 0,5ml/kg/h if urinary catheter
 No pain or mild pain (SVS 0 OR 1) without recent bolus of opioids (see pain chapter)
 Axillary temperature between 35.5 and 37°C
 Absence of nausea or vomiting
 If spinal anaesthesia, the patient should be able to move their legs and check for signs of urinary
retention
 Anaesthetist and surgeon have approved patient to be discharged from the PACU

The ward team should be told of patient transfer in advance and care should be handed over verbally
and in writing, to make sure care is continued. Detailed patient history including: name, age, past
medical history, surgery performed, complications and treatment during surgery and recovery room,
patient resources (family etc).

Postoperative note and orders from PACU

The patient should arrive on the ward with clear and complete records of the following:
 Vital signs
 Pain control
 Rate and type of intravenous fluid
 Urine, drainage and gastrointestinal fluid output
 Medications
 Laboratory investigations
 Any monitoring or interventions specific to the surgery (dressings, positioning/activity)
The patient should be monitored regularly and results should be written in the patient file. In addition,
the following should also be documented:
 A comment on medical and nursing observations
 A specific comment on the wound or operation site
 Any complications
 Any changes made in treatment

In ICU or surgical ward

The ICU or ward team should be told of the patient’s transfer in advance.
The nurse in charge of the patient must do the initial post-operative assessment. It must be done
immediately after the patient arrives and should provide the nursing staff with a complete patient
profile. The purpose of this is to provide a baseline that will allow the nurse or medical team to detect
any future complications. There should be a focus on the intra-operative course (what was done, what
happened), post-operative orders (important in knowing what the limitations and the specific
assessment elements required), monitoring (vital signs, respiratory function and mental status).
The initial assessment and management of the patient coming from PACU is the same as that for
immediate post surgery management in PACU (see above: When the patient arrives).
 Transfer the patient to the room/bed
 Detailed handover.
 Check the patient file:
 Check medications prescribed and plan the next doses (don’t forget the fluid rate)
 Prophylactic strategies (thromboprophylaxis, antibiotics, pain management)
 Nutrition requirements
 Any orders for activity restrictions: unless contraindicated, the patient should be mobilized as
soon as possible to reduce complications such as constipation, pressure sores, muscle
stiffness and pneumonia

The initial assessment must include a full physical assessment of the patient from
head to toe, on his/her arrival on the unit. It should also include a review of the
postoperative orders cited above.

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 Monitoring is more frequent at first and varies depending on the stability of the patient and risk of
deterioration. Vital signs should be recorded at least every hour for the first 4 hours, then 2 to 6
hourly, again depending on state of patient, for the first 24hrs.

Complications
Lung atelectasis (collapse)
See acute respiratory failure
Post-operative fever (≥38ᵒC)
Fever often occurs in the first 72hrs following major surgery. Note that if the fever is from a post-
operative response, it will be self-limited, not associated with haemodynamic instability, and does not
necessarily mean infection. However, fever in general can be due to a large number of infectious and
non- infectious causes, some of which are life threatening and need emergency management. So it is
important to assess the patient’s overall condition whenever a fever occurs.
The main causes
 Surgical site infections: Wound management should be done as per protocol, in an aseptic
(sterile) way. If no specific frequency is ordered, the dressing should usually be changed twice
daily, or when soiled. Note any change in the wound: redness, warmth, pus and pain. Inform the
doctor of any changes
 For prevention of respiratory infections:
 Encourage early mobilization
 Encourage deep breathing and coughing (incentive spirometry)
 Provide adequate pain control (making sure that breathing is not painful )
 Urine and IV catheter-associated infection (see Hygiene chapter)
 General inflammation secondary to surgery
 Drug reactions
 Malaria
Infection
Infection is not a complication that will occur in the first few post-operative hours, it will occur in the
following days. See the chapter on Hygiene and Nursing Care for more specific information.
Prevention

Hand hygiene is absolutely essential and should be done before and after
touching any patient or piece of equipment. All the equipment used should also be
cleaned appropriately.

 Pre surgery:
 Antiseptic shower with Polivyodine 4%
 Wear clean, dry clothes post shower.
 In surgery:
 Appropriate sterilisation of the instruments
 Good hygiene in the operating theatre
 Good scrub technique
 Follow the sterilising procedure
 Adhere to the antibiotic prophylaxis protocol
 Post surgery:
 Keep the wound covered by a closed, none permeable dressing
 Aseptic dressing change
Detection
 Observation of the surgical wound (colour, secretion, smell)
 Drain output type and amount (pus, blood, serous fluid)
 Monitor patient temperature

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Postoperative fluid intake and feeding

The time to restart oral intake depends on the type of surgery and the individual patient. This is one of
the reasons why it is important to be aware of the type of surgery the patient has had. Starting feeds
postoperatively is a medical decision, especially after gastrointestinal (GI) surgery. The decision is
made by the anaesthetist and the surgeon.

If the patient isn’t allowed to have oral intake (NPO = nothing per-os), think about providing frequent
mouth care (refer to the chapter on Nursing Cares).
After local or regional anaesthesia
Oral fluids and feeding can usually start when the patient returns to the ward.

After general anaesthesia

Except for some GI surgeries, patients can usually eat from 4 to 6 hours after the end of surgery. At
this time the nurse should perform a swallow evaluation with water before allowing the patient to eat
and drink. Healthy patients can drink and eat when they are FULLY awake following anaesthesia,
providing there are no medical, surgical or nursing contraindications.

Swallow evaluation
In order to assess whether a patient has a safe swallow, make sure the patient is alert and can follow
a series of commands. Position the patient in a sitting position (if no contraindications) with the head
of the bed as high as possible to prevent aspiration. Using drinkable water, ask the patient to take a
sip of water. Observe the patient during this process for any signs of aspiration:
 Coughing
 Gurgling, wet voice after swallowing
 Decrease in oxygen saturation by more than 2 points
 Shortness of breath, tachypnoea, or other signs of respiratory distress
If the patient swallows well with no complications, allow the patient to eat and drink.
If, however, the patient shows signs of aspiration as listed above, do not continue to give the patient
liquids. Rest the patient for 2 hours, and then repeat the swallow evaluation. If the patient still shows
signs of aspiration, consult the medical team.

Restarting oral intake in patients with potentially impaired airway reflexes and/or swallowing problems
(e.g. head-injured patients) requires caution and individual patient assessment. The patient may
require a modified consistency of foods, such as thick liquids or porridge, to avoid aspiration.

After GI surgery there is a slowing or stopping of gastric motility and peristalsis, which are the normal
motions of the stomach and bowel that move liquids along the GI tract for digestion and absorption.
Small bowel peristaltic activity usually restarts within 6-12hrs of planned or emergency GI surgery,
gastric motility within 24hrs and colonic activity by 48 to 72hrs

Early feeding, in patients without contraindications, provides good protection against many
complications:
 Early recovery of GI function
 Better wound healing (less chance of infection)
 Reduces wound or anastomotic breakdown
 Shorter hospital stay
 Less weight loss and muscular atrophy (wasting)
 Increased immunity
Feeding can safely begin before passage of flatus or stool and in absence of bowel sounds. Feeding
stimulates bowel motility, promoting the return of bowel functions.

Patients are best fed based on their appetite and food preference.

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 Transport

Transport
Severely ill patients may need to go to another hospital for special care, tests or other services not
available at your hospital.
The transport of a severely ill patient has to be planned carefully as the patient’s condition can worsen
on the way. The nurse is alone with the driver and attendants, outside the hospital and without all the
usual equipment. It can be very stressful.
The nurse transferring the patient has to be properly trained and fully understand the patient’s
condition. The ambulance has to have the right equipment which should be checked thoroughly by the
nurses to make sure everything is present and working properly. The patient has to be in a stable
condition before they are transferred and the nurse familiar with all emergency equipment should it be
needed. Even in an emergency situation, everything has to be planned and well prepared. The referral
will be useless if the patient dies on the way.
The referral hospital has to be informed of the transfer and a proper handover has to be done by
phone, so the team can prepare for the patient’s arrival. A referral letter should be written and given to
the receiving staff on arrival and a thorough verbal handover given.

The patient
The first rule is to never start moving an unstable patient. If the patient is in shock, transfer them only
after they are treated and stabilised.
 Prepare, check and secure all the medical equipment on the patient (IV lines, urinary catheter,
drains, traction)
 Tell the patient that he will be transferred to another hospital (if conscious) or/and his family or
relatives.
 Transfer the patient and all the equipment in a safe and comfortable position on the stretcher
 Cover the patient to protect his privacy and keep him warm during the trip
 A nurse has to stay with the patient all the time between his room and the ambulance to make
sure the patient and all equipment are closely observed.

Never leave a critically ill patient alone”

 Go inside the ambulance first to receive the patient. The nurse should stay at the patient’s head
and should be the person responsible for the safe transfer of the patient inside the ambulance.
Care should be taken that drains, IV lines and anything else attached to the patient do not get
removed, and block immobilisation should be carefully maintained for spinal injury patients.
 When the patient is inside the ambulance, install all the medical devices and equipment required
during the journey.
 If other people will be travelling with the ambulance, organize the position of everyone inside to
keep a clear area to manage the patient.
 Check if everything is ready before the ambulance leaves
 Patient file/records
 Referral letter
 Referral consent form
 Equipment and drugs

The staff
During the transfer, the nurse in charge will be alone and may need to resuscitate or do a procedure
on the patient. It is therefore essential that:
 Special training should be given to all nurses likely to transfer patients.
 The nurse knows what equipment is on the ambulance and how to use it.
 If the driver is given first aid training, this could save a life as he can assist the nurse with an
emergency or resuscitation on the journey
 The nurse should carry a mobile phone to call the doctor for any advice or an oral prescription
during the trip.

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The ambulance and the equipment

The ambulance equipment has to be well organised and easily within reach for the transfer nurse to
use. The whole ambulance has to be checked and cleaned after each transfer. The driver will be in
charge of non-medical equipment and the nurse of medical equipment and drugs.
 A check list is very useful to avoid leaving anything out
 Organize the equipment according to how it will be used which will be more efficient and
convenient in an emergency situation.
 Airway and respiration: Nasal prongs, mask, ambu bag, Guedel airway, suction and tubes
 Circulation: IV catheter, fluids (NaCl, Ringer lactate…), syringes, needles
 Dressing: Compresses, antiseptics, crepe bandage, tape
 Equipment: Pulse oxymeter, blood pressure measurer/cuff, stethoscope, thermometer,
glucometer with full batteries.
 Standard protection for the staff: Gloves, mask, hydro-alcoholic solution, sharps-box
 Overall cleanliness of the ambulance is the nurse’s responsibility
 Oxygen cylinder has to be checked before each transfer (refer to appendix ……table of oxygen
cylinder capacity)
 Emergency drugs should be in a safe place. Check expiry dates (Adrenaline, Atropine, Diazepam,
Painkiller, G30%, Furosemide...) and any specific drugs prescribed. The drugs box can be stored
in the nursing station when not used.

Handing over the patient to the referral hospital

Always tell the receiving hospital when you leave and tell them the approximate arrival time.
At the same time, tell the team receiving the patient information about the patient’s condition and what
medical equipment they will need to prepare. This will save time at the time of the patient’s arrival and
improve efficiency.
A referral letter provided by the doctor should be given to the receiving team. This should include
information about the patient, what procedures have been done and what drugs are being given.
Clinical handover (See handover chapter). Do not leave the patient until the patient is stable.

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 Severe Malaria

Severe malaria
Malaria is an infection caused by a parasite transmitted to humans by the bite of mosquitoes. It is
possible to get malaria from a blood transfusion that contains the parasite and it can also be passed to
new-born babies through the mother’s placenta.

Severe malaria causes organ failure due to infected red blood cells in the microcirculation. In areas
where malaria is common, young children and pregnant women are especially at risk Death due to
severe malaria can occur within a few hours, so it is essential to make a diagnosis and start treatment
early.
Malaria is first suspected based on clinical signs and then confirmed by seeing parasites or malaria
antigens, detected by a rapid diagnostic test (RDT) in the blood.
When no other diagnosis has been found, patients showing symptoms of severe malaria, even if they
have a negative test, should be started on treatment, but other reasons for their symptoms should be
looked for.

Clinical manifestations
Malaria should always be considered in a patient who presents with fever (or history of fever in the
previous 48 hours), if they have been living in or coming from an area where malaria is present,

Cerebral malaria
Severe/complicated malaria and is characterised by
 Altered conscious level, confusion or coma
 Seizures, generalised or focal (e.g. abnormal eye movements)
 Extreme weakness
In addition the patient may have the same symtoms as uncomplicated malaria such as headache,
muscular pain, abdominal pain and diarrhoea. Vomiting may also be present.
The final diagnosis should be confirmed using a Rapid Diagnostic Test (RDT) or microscopy (thick or
thin smear).

Clinical Tests
Altered conscious level (incl. coma) Hypoglycaemia
Extreme weakness Severe anaemia (Hb<5g/dL)
Multiple convulsions (>2 in 24h) Haemoglobinuria (urinary dipstick)
Acute respiratory distress Increased urea or creatinine
Circulatory collapse or shock Pulmonary oedema (on X-ray)
Acute kidney injury
Haemoglobinuria (urine colour like Coca-Cola)
Abnormal bleeding
Table 1. Features of severe malaria

In children
Seizures secondary to malaria tend to present with coma lasting more than 30 minutes after seizure.
However, malaria, can also cause a high fever which could result in seizures.
Be more careful regarding dehydration (fever, inability to drink/suck)
In children under 5 years old living in areas of high malaria transmission, the main types of severe
malaria that we see are severe malarial anaemia (mainly in children under 3 years), cerebral malaria
(more frequent in children 3-6 years old) and severe malaria with hypoglycaemia.

Management
 A complete head to toe assessment has to be done as for any new patient in ICU and any ward.
This assessment should be repeated and recorded regularly to make sure any abnormalities are
detected.
 Vitals (HR, BP, RR, SpO2, T°C, Glycaemia, Diuresis)
 Neurological assessment (AVPU, agitation, coma, convulsion)
 Make and record a full clinical assessment (jaundice, pallor, signs of respiratory distress)
 Pain scale

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 Oxygen has to be started quickly for all patients with severe anaemia, altered consciousness or
desaturation.
 Control fever (external cooling, paracetamol) to keep temperature below 38,5°C.
 Nursing care for coma and convulsion patients (refer to Neurology and Nursing Care chapter).
 Monitor haemoglobin level and use the following transfusion guidelines (refer to Blood transfusion
chapter)
 For adults and pregnant women < 36 weeks: Hb <7g/dL
 For pregnant women > 36 weeks: Hb < 8g/dl
 For children: Hb < 4g/dl or 4 g/dl < Hb < 6g/dl if there are signs of decompensation
(respiratory distress)
 Closely observe the glucose levels in patients with impaired consciousness and/or extreme
weakness
 Rehydration and enteral feeding (for patients unable to swallow) have to be given as soon as
possible.
 Patients with malaria seem to be more likely to suffer from the side effects of fluid overload. How
much fluid the patient needs should be assessed on an individual basis, as there is just a small
line between hypovolemia (risk of acute kidney injury) and hypervolemia (risk of pulmonary and
cerebral oedema).
 The usual care of the intensive care patient is needed. (refer to Nursing assessment chapter).
 Treatment for severe malaria should first be given in IV line. Treatment should be changed to oral
treatment as soon as the patient recovers consciousness or is not in a life-threatening situation
after a minimum of 24h. Injectable Artesunate is the first choice for treatment of severe malaria.
Arthemeter or quinine can also be used if Artesunate is not available.
 IV treatment of severe malaria should be followed by a full course of oral drugs
 Antibiotics have to be considered in severe malaria when it is thought a bacterial infection is also
present.

The risk of hypoglycaemia is higher in patients receiving IV quinine, especially

pregnant women, and glucose should be closely monitored

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 Nursing assessment

Nursing assessment
The aim of the nursing assessment of a critically ill patient is to identify any abnormalities, to decide on
priorities of care and to help with clinical decision-making.
There are a number of assessments that can be done on a patient, depending on the need. The first
assessment is the emergency assessment (refer to Emergency Assessment chapter). Once the
patient’s condition has been stabilised, the secondary assessment is done.

Secondary assessment
The secondary assessment is a head-to-toe nursing assessment of the patient’s major body systems
to identify and treat any abnormal conditions. It should be done on any patient you are looking after,
whether it is at the start of your shift, the patient has arrived in the ICU post operatively, or if there is a
change in your patient’s clinical condition.
Close monitoring of critically ill patients is extremely important. Nurses should measure vital signs
frequently (hourly or even more frequently, depending on how sick the patient is), and be given
specific instructions on what to do if the patient’s vital signs change.

Head
 Evaluate patient’s mental status and level of consciousness with the Glasgow Coma Scale
 Assess pupils for size, shape and reaction to light.
 Assess upper and lower limb strength
 Assess patient’s communication (ability to speak) and provide communication tools if needed
 Assess patient’s level of pain using an appropriate pain assessment tool

Airway
Assess airway patency :
 Listen for stridor, wheeze, gurgling, hoarse voice or silence.
 Abnormal chest movement may indicate airway obstruction.

Breathing
 Observe the respiratory rate, depth of breathing and SpO2.
 Look for signs of increased difficulty in breathing such as :
 increased respiratory rate
 shallow breathing
 use of accessory muscles
 nasal flaring
 paradoxical abdominal breathing and forward posture.
 Assess for signs of respiratory depression such as :
 low respiratory rate
 shallow breathing.
 Listen to the lungs to assess air entry and to identify any abnormal breath sounds
 Are breath sounds normal, reduced or absent?
 Are breath sounds between the right and left sides of the chest equal or unequal?
 Are there any abnormal breath sounds such as wheezing or crackles?
 Assess strength of cough reflex and how much sputum is being produced. If sputum is being
produced, describe the amount, colour and consistency of sputum.
 Monitor thoracic drain: quantity, bubbles, colour
 Assess thoracic drain insertion site and dressing

Figure 1a & 1b: Listen to breath sounds bilaterally

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Circulation
Non-invasive blood pressure measurement
The accuracy of a blood pressure reading depends on the size of the cuff which should be 40% of the
circumference of the arm (Figure 2).

Figure 2. The size of the cuff should be correct so as to give an accurate reading

Lie the patient down or put them in a sitting position

The leg is an option if the arm is not possible but you have to lie the patient flat with the legs at the
same level as the rest of the body.
Heart rate monitoring
Descriptions: regular, irregular, strong or weak
Continuous 3-lead or 5-lead ECG monitoring is common in the ICU and allows the patient’s heart rate
and rhythm to be continuously monitored and recorded. If only one single lead is displayed, the usual
lead is lead II. The usual amplitude is 1 mV/cm.
A slow heart rate will reduce cardiac output, unless the patient is able to increase stroke volume. Very
fast heart rates may result in insufficient time for ventricular filling, reducing cardiac output.

Figure 3. Positioning of 3-lead (left) and 5-lead (right) ECG monitoring

Limbs
 Test capillary refill; it should be <2 seconds.
 Observe hands and feet for swelling/oedema
 Assess skin colour, temperature and moisture:
 Is the skin pink, pale or white?
 Is the skin warm, cool or cold?
 Is the skin dry, moist or wet?
 Assess whether pulses are present.
 Assess IV access. Make sure lines are properly dressed, well secured, and observe for signs of
infection and patency.
Gastrointestinal tract
 Listen for the presence of bowel sounds
 Palpate the abdomen, checking for signs of distension, rigidity, masses and tenderness.

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 Check when the patient last had their bowels open and assess the need for aperients (medication
that helps the patient pass faeces)
 Assess the patient’s diet

Figure 4. Place the diaphragm of the stethoscope on the patient’s abdomen. Listen to the four upper and lower quadrants for
bowel sounds.

Genitourinary
 Make sure urinary catheter is patent and secure
 Observe urine output for previous hours (oliguria < 0,5ml/kg/h)
 Observe colour and consistency of urine
 Assess fluid balance for previous 24 hours
Skin
 Examine the condition of the skin and note any skin tears, wounds, inflammation or pressure sores.
 Observe wounds, including surgical wounds for signs of infection or bleeding and assess the
condition of wound dressings.
 Observe any wound drains for security and output.

Figure 5. Examine the skin condition for any abrasions (scratches), wounds or inflammation, examine the buttocks for any sores
and the calves for any tenderness, pain or swelling, which may be signs or symptoms of DVT.

Don’t forget to monitor and assess any skin problems

HemoCue
 The skin used should be clean and dry.
 You can use the fingers (lateral surface of the 3rd phalange, avoid thumb and index fingers), toes,
ear lobe.
 Remove the first drop of blood and take the second
 Record the result in the patient’s file and inform the doctor if the result is abnormal.
Glucose
 High and low blood glucose concentrations are common in critically ill patients, and blood glucose
should be checked routinely in all patients and regularly in patients receiving enteral feeding by
NG tube or who are being given insulin.
 ALWAYS check for low blood glucose in patients with a reduced conscious level or who are
having seizures.
 A rise in blood glucose may simply be a sign of the body’s response to stress. However, the
possibility of diabetes and particularly a complication of diabetes (eg ketoacidosis or coma) should
be considered.

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How test the blood glucose

 The skin has to be clean and dry. After eating, the result can be wrong because of sugar on the
skin surface. Ask the patient to clean his hand with soap and water. Alcohol cleaning solution can
modify the glucose level result.
 You can use the fingers (lateral surface of the 3rd phalange, avoid thumb and index finger, toes,
ear lobe.
 Record the result in the patient’s file and inform the doctor if the result is abdnormal.
 Glucometer indicators
 Hi = High mean: too high to give an accurate result
 Lo = Low mean: too low to give an accurate result
 For both, emergency treatment should be started s soon as possible
Blood results
 Check the patient’s most recent blood results
Medications
 Observe the patient’s medication chart. Assess individual medications for reasons given,
contraindications, etc. and note when medications are next due.
 Make sure there are enough fluids prescribed and that they are in stock.
 Make sure enteral feeding is running at the correct speed as per the medical prescription.

After the assessement

Record in the patient’s file:
 all the information you have observed during the assessment (vital signs, colour of the patient,
cyanosis, urine and secretions …)
 all the medications and infusions you have given to the patient (pills, perfusion, aerosol…)
 all the procedures you have done to the patient (dressings, suction, massage…)
Report any concerns or abnormal findings from the secondary assessment to the medical team.

Figure 6. Summary of head-to-toe assessment points

Regular bedside safety check

The purpose of the bedside safety check is to check the patient, all equipment and the environment
around the bedside to make sure that there are no immediate safety risks to the patient and that all
emergency equipment is ready, clean, and immediately available.
These checks should be done by the nurse caring for the patient and should happen at least once per
shift, (ideally at the beginning of the shift), along with the nurse who is handing over care of the

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patient. They should also be performed any time the patient is moved ie arrives from another ward or
returns from a procedure.

Remember, always check the patient first!

If there are any signs of emergency, perform a rapid patient assessment first. Management of an
emergency will include checking the equipment, but assessment of the patient is the first priority.

Bed space assessment

 Make sure the patient’s bed space is clean and free of unnecessary objects
 Make sure the bed space is adequately stocked and emergency equipment is readily available.
 Note the location of the emergency trolley in relation to your patient’s bed space

Bedside safety check

Airway
 Is there a new oral airway close at hand in case it’s needed?
 Is there a bag-valve-mask available to use if the patient stops breathing?
 Is there suction nearby? Is it working?
Breathing
 Is there an oxygen source nearby? Is it working?
 Is there tubing and an appropriate oxygen mask ready and close by?
 If the patient is on oxygen therapy, does the flow match the prescription?
Circulation
 Is there an emergency trolley nearby with the correct equipment in case of cardiac arrest?
 Is the central venous catheter suture secure? Are all peripheral IV’s secured? Are all unused IV’s
and lumens closed, flushed, and capped? Are all IV infusion connections tight?
 Are IV fluids infusing according to prescription? Are they correctly labelled?
 If the patient is on a continuous infusion of vasoactive medication, does the syringe still have
enough volume, or is it due to be changed soon?
 Are all IV catheters and tubing marked with the date to be changed?
 Is there an unused, patent IV catheter to use in case of emergency? If not, is there an infusion that
can be temporarily disconnected in order to flush through emergency drugs?
 Are alarm limits adjusted correctly according to the patient’s needs?
General
 Are all other drains and tubes secure?
 Are all pumps and electrical equipment connected to a power source?
 Is the patient at risk of falling? If so, is there a family member with the patient? Are the wheels
locked on the bed? Are there any railings that can be put up on the bed?

All resuscitation equipment should be ready in case it is needed. All staff should be
aware of the location of emergency equipment, how to use it and how to prepare
and dilute all drugs

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Nursing care
Critically ill patients are completely dependent on the medical team to detect, diagnose and treat their
problems and to assist them with the activities of daily life that they are unable to do themselves.
Always remember, critically ill patients are more vulnerable than others patients. As nurses, it is our
job to not only give the patients good quality care, but also to help protect them from infection,
accidents, and complications of treatment and therefore give them the best possible chance of
survival and recovery.

At the beginning of the shift, look at the patient as a whole and be able to answer the following
questions:
 Why is my patient in the critical care ward?
 What caused this patient's illness/injury?
 Based on this information, what are the greatest risks for complications for this particular patient?

You should then make a daily nursing plan in order to make sure all the patient’s needs are met in
order of priority, and to minimize/avoid any possible complications.
Make sure aseptic dressings (IV line or clean surgical dressings) are done before dirty procedures
(ostomy, infected dressings) to avoid cross infection.

The cleanest to the dirtiest

Make sure that the patient, their families and other caregivers are aware of this plan. Always be aware
that a critically ill patient’s situation can change very quickly and be prepared for any emergency
situation should it arise.

Mouth care
In ICU, mouth care is part of the nurse’s job. The aim is to keep the mouth moist, the teeth clean and
to prevent bad smells and local infection.

Technique
First explain the procedure to the patient (if conscious) and put them into a sitting position if possible
depending on their medical condition. Put a towel or tissue on the patient’s chest and examine the
mouth to see if it is normal or if there are signs of inflammation, ulceration, fungus or bleeding. Inform
the doctor about your observation and act on medical advice.

Use diluted iodine solution (1/4 iodine and 3/4 drinking water) or chlorhexidine 0.12%. For patients
with oral candida use diluted sodium bicarbonate solution.
Wash first: lips, gums, teeth, inside of cheeks, palate and tongue with wet gauze until clean (figure 1).
Brush the teeth, rinse and use suction to remove all the fluids from inside the mouth.
Remember that the patient is at risk of aspiration from this procedure. If they are unable to protect
their airway, use suction during whole the process.

 Badly cleaned teeth can cause infection of the gums that can cause loss of teeth.
 Frequency: 6 times a day (every 4 hours): brushing teeth and disinfecting with gauze
 Toothpaste is not necessary. Brushing is more important.
 For a conscious patient, brush teeth 2 times a day (toothbrush with toothpaste), let the patient do
it if possible, this is a good exercise to help them regain their independence.
 Do not brush the teeth of patients with abnormal clotting, only use gauze.

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Figure 1. Mouth care

Preventing complications of immobilization

Any patient lying in a hospital bed with limited movement will be at risk of complications from
immobility.
 Deep Vein Thrombosis (DVT) and pulmonary embolism
 Bed sores (pressure ulcers)
 Bronchial stasis and atelectasis
 Urinary retention
 Constipation
 Muscle atrophy
 Depression
It is always better to start helping the patient move out of bed as soon as it is safe and medically
appropriate to do so. Early mobilisation of patients can prevent many complications.
 Active daily exercise (help the patient to do this themselves as much as possible)
 Exercise the joints within their normal range of movement.
 Muscular strengthening
 Provide walking aids such as canes, crutches and walkers and give instructions for their use.
When the patient gets out of bed for the first time, it should always be with the help of medical
staff to help prevent the patient from falling.
 Turn the patient/change their position frequently.

Deep vein thrombosis (DVT)

In the patient with limited mobility, the blood in the legs doesn’t circulate as well as when the patient is
active and moving. The blood pools in the leg veins, and can easily form clots. If one of these clots
gets dislodged, it can travel to the lungs, causing a pulmonary embolism, which can be life-
threatening (refer to Acute respiratory failure chapter). DVT occurs frequently in hospitalised surgical
patients, is often difficult to detect, and the results can be seriously disabling, even fatal. Prevention is
very important by reducing the risk factors and using mechanical or drug prophylaxis.
Prevention
 Early mobilisation. Help the patient to change positions often, or to get out of bed to move around
if it is safe and appropriate.
 If available, compression bandages or stockings can be placed on the legs to help with blood
return. Elevating the lower limbs prevents blood from pooling in the veins.
 Drug thromboprophylaxis (Enoxaparine, Nardroparine) if there are no contraindications to
receiving anti-coagulants, such as; allergy, uncorrected bleeding disorders, active major bleeding
Signs of DVT
 Unilateral (only one leg, usually calf)

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 Acute leg pain, made worse during foot extension

 Swelling
 Tenderness
 Redness
 Warmth

Any patient with a DVT must be monitored closely to detect for early signs of
pulmonary embolism. Strict bedrest is needed at the beginning to prevent
dislodging the clot.

Pressure ulcers
Breakdown of the skin over the bony areas of the body, or pressure areas, can happen very quickly
for patients who are not able to move their position. It is much easier and better for the patient to
prevent this skin breakdown than to treat it after it develops. Do the following to prevent skin
breakdown and pressure ulcers:
 If the patient can move in bed, ask them to change their position frequently to avoid pressure on
the same areas.
 If the patient cannot change position on their own in bed help them to turn from side to side,
supporting their position with pillows. Ideally, this should be done once every two hours, but at the
very least once every four hours.
 To move the patient, use a draw sheet to lift and reposition them. Never drag the patient over the
bed sheets without using a sheet as this can damage the skin and cause skin breakdown.
 Make sure the patient is getting proper nutrition and a high protein diet
 Make sure the patient’s skin remains clean and dry. If the patient is incontinent, change the bed
sheets as soon as they are wet or soiled, and if possible, use pads that draw moisture away from
the skin. Clean and dry the patient well after any incontinence, and apply creams that protect the
skin from moisture.
 Perform an assessment of all the patient’s bony pressure areas (including the hip bones, coccyx,
sacrum, shoulders and spine, elbows, and heels) at least once a shift to look for skin breakdown.-
 If you see redness that does not turn white when you press the skin with your finger, this is the
first stage of a pressure ulcer. This should be noted in the patient’s chart and all caregivers should
be sure to follow strict skin care to try to prevent it from developing further.
 If the skin is broken and the pressure ulcer reaches below the first layer of skin (stage 2), to the
fatty tissue (stage 3), or to tendons and bone (stage 4), these are more advanced pressure ulcers
and must be dressed with special wound care dressings and a strict skincare routine should be
continued.

Passive exercises
 Passive exercises should be done twice a day, by supporting the limb below and above the joint
and moving the joint gently and slowly backwards and forwards. Passive movement exercises
should be performed on the knees, ankles, hips, shoulder, wrists, elbows, fingers and toes.

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Infection control
Why is it important?
Although ICU is an area where the patient can receive life-saving treatments, it is also an area that
exposes them to risks. Patients can have lowered immunity due to their illness, (especially septic
patients), can suffer from nosocomial (hospital acquired) infections, or the adverse effects of the
invasive monitoring used in ICU (catheter, tubes, dressings…).

Nosocomial infections may be acquired from other patients, hospital staff, contaminated objects or
solutions, or from the patient (including transferal of germs from one part of the body to another). The
most common nosocomial infections in the ICU are respiratory tract, bloodstream and urinary tract
infections.

Nurses play a very important role in preventing and controlling infections in hospital. It is important for
them to understand the rules for preventing infection, so that they can carry out infection-control
measures properly and check that all staff are following the correct procedures.
Carers (including family) can also spread nosocomial infection by sharing meals, bed…with their
relatives.
It is everyone’s job to maintain good infection control.

Hand Hygiene
Hand hygiene is the single most important practice in infection control. About 80% of all nosocomial
infections are carried on the hands, and passed on to the patient by healthcare workers. Cross-
infection can be greatly reduced when nurses clean their hands using the correct technique, at the
correct times. It is the role of each nurse to work with the nursing team towards better hand hygiene.
Alcohol rub should be placed as close as possible to the working space.
All the staff must know how to perform a proper hand hygiene technique (figure 1).

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How to clean your hands

Apply a palmful of hand-rub or Rub hands palm to palm Rub palm of right hand over back of left
disinfectant soap with water to cupped hand with fingers interlaced and vice
hands versa

Rub hands palm to palm with fingers Rotational rubbing of left thumb clasped Rub back of fingers against opposite
interlaced in right hand and vice versa palm with fingers interlocked

Hands should be rubbed until dry if

using hand rub or should be dried
thoroughly with clean paper towels if
they have been washed. Drying is an
important part of the process and should
not be left out.

Rotational rubbing, backwards and Rotational rubbing of both wrists

forwards, with clasped fingers of right
hand in left palm and vice versa

Do not forget outer sides of hands and wrists”

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When to clean your hands

Immediately before putting on

gloves and immediately after
taking off gloves

Immediately before touching the Immediately before clean/aseptic

patient: to protect the patient against procedures: to protect the patient
harmful germs carried on the health against harmful germs (including
worker’s hand (example: shaking his/her own) entering his/her body
hands, applying oxygen mask, taking (example: inserting intravenous
pulse). catheter, preparation of medication).

Immediately after touching the Immediately after body fluid Immediately after contact with
patient: to protect health care worker exposure: to protect the health care patient’s surroundings: to protect
and health care area from harmful worker and the health care area from health care worker and health care
germs (example: helping a patient to contamination from patient’s harmful area from harmful germs (example:
move, applying oxygen mask, taking germs (example: brushing patient’s clearing bedside table, adjusting an
pulse). teeth, emptying urine bag, handling infusion, touching a monitoring device).
visibly soiled linen).

Figure 2. When to clean your hands

When to use soap vs. hand-gel

In general hand gel is more convenient if it is available. There are a few times when it is recommended
to use soap and water instead of hand gel:
 At the beginning of the shift
 When hands become visibly dirty or soiled
 After using the toilet
 “Social indications,” such as rest breaks, meal breaks, before any clean activities (handling food)
 For any patient with a Clostridium difficile infection, soap and water must be used as alcohol hand
rub does not kill this bacteria.

Methods of preventing infection

There are different methods to protect patients and medical staff from getting infections. These
methods are called types of precautions, and they can be divided into categories based on how the
particular infection is transmitted from person to person. Be aware that more than one type of
precaution may be needed for the same patient.

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Standard Precautions
Must be followed for all patients, at all times. Often it is unknown whether a patient has an infection,
and so these precautions are meant to be a standard, basic level of protection against possible
infections.
 Hand hygiene (see above)
 Gloves, gowns and eye protection must be used as mentioned above, in situations where
exposure to body secretions or blood is possible. This personal protection equipment must be
changed between patients and hands must be cleaned.
 All staff, patients, and visitors must do the following if they have a cough: use a tissue when
coughing or sneezing, do not cough or sneeze directly into the hand. Provide tissues for staff,
patients and visitors, and perform hand hygiene after using a tissue. If tissues are unavailable,
cough or sneeze into the bend of the elbow, not into the bare hand.
 Any staff or visitors with respiratory symptoms should avoid patient care areas, if possible. If not
possible, they must wear a mask to protect patients from infection.
 Soiled linen must be disposed of in waterproof bags or closed linen buckets.
 Blood, faeces, urine and anything contaminated with these must be disposed of in proper sanitary
facilities.
 Wear a mask during procedures that will puncture the spinal space (lumbar puncture, spinal block).
 Safe injection practices must be followed, as below:
 Sharp instruments and needles must be disposed of safely in special containers that can be
closed and cannot leak or be punctured.
 Sharps container should be brought to the bed-side when using needles and discarded
immediately after puncture.
 Use one syringe and needle for one use on one patient only. Never re-introduce a used
needle into a vial or solution, and never use the same needle, syringe, or IV administration set
on more than one patient.
 Disinfect the rubber stopper of drug vials with alcohol before inserting the needle. Disinfect the
patient’s injection site or the IV catheter hub before administration.

Make sure reusable equipment is not used for the care of another patient until it
has been cleaned and reprocessed properly. Make sure that single-use items are
thrown away immediately and properly.

Contact Precautions
As well as standard precautions, contact precautions are designed to prevent infections that can be
spread by direct patient contact or by indirect contact with objects and/or environmental surfaces.
Common examples include respiratory viruses, GI tract viruses, viral hemorrhagic fever, cholera and
multi-resistant bacteria.
 Patients should be isolated or looked after with patients who have the same infection
 Put on gloves and an apron/gown before entering the room in case there is any contact with the
patient. Even if patients are infected with the same (multi-resistant) micro-organism, the gowns
and the gloves should be changed in between each patient and hands disinfected.
 Use dedicated (used only for that patient) individual equipment, especially for reusable medical
devices, for the patient under contact precautions (dressing tray, stethoscopes,
sphygmomanometer, tourniquet)
 All protective equipment must be removed before leaving the infected areas, then perform hand
hygiene.
 Indentify and clearly label the isolation area

Droplet Precautions
As well as standard precautions, extra precautions should be taken to prevent the transmission of
infections that are spread by droplets. Respiratory droplets are produced when an infected person
coughs, sneezes, or talks during procedures such as suctioning or intubation. Examples of micro-
organisms that require droplet precautions include Influenza, Neisseria meningitis and whooping
cough virus.
 Patients should be isolated in single rooms if possible

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 Wear a surgical face-mask when within 1-2 meters of the patient

 Hand hygiene should be performed before and after wearing the mask
 Eye protection, such as visors, full face shields or goggles are optional and depend on specific
circumstances, e.g. excessive patient coughing, closeness of contact and need for performing
high-risk procedures.

Airborne Precautions
As well as standard precautions, airborne precautions should be used in the care of patients with
suspected or confirmed infections known to be airborne, or of newly recognized infections before the
way they are spread is known. Common examples of micro-organisms that require airborne
precautions include tuberculosis, measles and varicella, the plague and some viral hemorrhagic fevers.
 Patients should be nursed in a single room. Ideally, this should be an isolation room
 When entering the room, wear a mask respirator (FFP2) with a particle filtering capacity that
allows a tight seal over the nose and mouth. Adjust the metallic part of the mask over the nose to
your nose shape. There is a big difference between different makes of masks in terms of fit. For
this reason, the wearer should be fit tested to make sure that their mask fits properly before using
it in a contaminated area. These respirators do not work if placed over facial hair. Not shaving for
more than 24 hours may be enough to cause a significant leak.
 Hand hygiene should be performed before and after wearing the mask
 Instruct the patient to wear a facemask when leaving his/her room
 Follow all guidelines for putting on the mask and performing a fit test.
 After putting on the mask, carry out both positive and negative pressure fit checks.
 Take a deep breath in and blow out hard, feeling for a leak around the mask. If you can feel a
leak, re-adjust the mask and repeat the test until no leak can be felt
 The negative pressure fit check is similar to a positive pressure fit check except that you feel
for a leak during inspiration.
 Eye protection, such as face shields or goggles, are optional and depend on specific
circumstances, e.g. excessive patient coughing, closeness of contact, need for high-risk
procedures.

It may be necessary to restrict access of visitors/family to protect the community”

Environmental infection Control

 There should be adequate procedures for the routine care, cleaning, and disinfection of
environmental surfaces. Avoid unnecessarily touching the following:
 Beds, bedrails, bedside equipment
 Stethoscopes
 Measuring tapes
 Torches
 Clean your hands before and after using common touch items:
 Keyboards
 Telephones
 Personal equipment
 Pagers, mobile phones, pens etc.
 The bed area and all surrounding equipment should be thoroughly cleaned between patients.

Strategies for preventing nosocomial infections

Catheter-associated urinary tract infection (CAUTI)
The urinary catheter may put patients at risk of urinary tract infection. It allows bacterial growth and
provides an entrance to the body. The longer the catheter is in place, the greater the chance of
infection. This urinary tract infection is called catheter-associated urinary tract infection (CAUTI).

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Planning and appropriate use of urinary catheters

 Avoid unnecessary urinary catheterization: The best way to prevent a CAUTI is to not insert a
catheter at all if it is not needed. Catheters should be put in for appropriate medical reasons, but
not:
 as a way to get a urine sample if the patient can pass urine on their own.
 as a substitute for nursing care in an incontinent patient
 as a way to avoid having to take the patient to the bathroom or use a bedpan
 Shorten the length of time the indwelling urinary catheter is in the patient. Catheter should be
removed if no longer medically necessary
Proper insertion of urinary catheters
Use aseptic technique when performing urinary catheter insertion
 Staff should be trained
 Use sterile equipment and single-use items only (catheter, gauze, gloves, new lubricant jelly, new
drainage bag)
 Use aseptic technique when inserting the catheter and when connecting the catheter to the
drainage bag
Proper maintenance of urinary catheters
 Make sure the urine can flow freely.
 Prevent kinking (bending) or sagging of the catheter.
 Keep the urine drainage bag below the level of the bladder. If it must be raised, clamp the
catheter or empty/change the urine bag to prevent backflow of urine into the bladder
 Make sure the drainage bag is emptied/changed on time to prevent overfilling
 The drainage bag must be hung on the side of the bed and not on the floor
 Maintain a sterile and closed system
 Minimize opening and handling of the catheter and the drainage bag. Secure the catheter to
the leg with tape to avoid it pulling and moving around too much. Tape the connection from
the catheter to the drainage system to avoid accidental disconnection.
 If any disconnection of any portion of the drainage system is needed, such as when changing
a drainage bag, the area where it has become disconnected must be disinfected first with
alcohol, and the catheter and drainage system should be handled with aseptic non-touch
technique until reconnected.
 When collecting a urine sample, use Chlorhexidine in alcohol base or iodine povidone to
disinfect the sampling port and allow it to dry thoroughly. Then use a sterile syringe and
needle to take a sample from the sampling port using aseptic technique.
 Patient hygiene measures:
 Always follow proper guidelines for hand hygiene and glove use
 Do daily care of the catheter and the meatus (area where the urinary catheter leaves the
body) by cleansing with soap and water and keep the area clean and dry

Surgical site infection (SSI)

Surgical site infection can be a very serious and common complication after surgery. With proper
prevention before, during, and after surgery, these patients will have a much greater chance of
avoiding this dangerous complication.
Preoperative prevention measures
 Use appropriate antiseptic agent and technique for skin preparation, as ordered.
 Do not shave the perioperative area, unless excess hair will interfere with the surgery.
 Antibiotic-prophylaxis: give antibiotics as ordered by the physician, according to the correct
prescribed time relative to the time of surgery.
 Tell the medical team if the patient shows signs of a new infection (fever, altered mental status,
new cough, etc) before surgery. The team may decide if the surgery needs to be postponed to
treat the new infection first.
Postoperative prevention measures
 Protect the surgical site with the sterile dressing placed by the surgeon for at least the first 24
hours, until the physician orders the dressing to be removed and changed.

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 If there is slight leakage around the original surgical dressing, place more gauze or dressing
pads over the original dressing.
 Tell the physician if there is excessive drainage. Notify them immediately if there is
uncontrolled bleeding or signs that the surgical wound has reopened.

Never open the surgical dressing immediately after surgery without medical
instructions

 Maintain normal blood glucose levels immediately after surgery (administer glucose for
hypoglycemia as per ward protocol, inform the physician of hyperglycaemia)
 Keep the patient clean. Stimulate him to have a bed bath (ask family to help if possible).

Detection of infections
When collecting samples for culture, care must be taken to avoid contamination of the sample from
any other surface, to reduce the risk of a false positive result.

Blood Culture
Make sure you disinfect the site of venipuncture very well with chlorhexidine in alcohol base or iodine
povidone before obtaining the sample. Try to use a non-touch technique and sterile syringes, needles,
gloves and other supplies.

Sputum Culture
Ask them to take deep breath and give a strong cough to obtain a sample from the distal bronchial tree,
and not saliva sputum (ask for help from the physiotherapist if needed).

Urine Culture
For patients with a urinary catheter: clamp the Foley, disconnect using sterile gauze and gloves, take
the sample of urine, reconnect aseptically and unclamp the Foley catheter. Do not take a urine culture
sample from the outlet of the urine bag.
For patients able to pass urine on their own: ask the patient to clean his/her genitals with iodine
povidone, open the collection bottle without touching inside (so as not to contaminate it) and to pass
urine inside.

Personal Protective Equipment

Gloves
 Single use
 Wear clean gloves when there is a reasonable chance that there will be contact with blood or body
fluids, mucous membranes, non-intact skin, or possibly infectious material.
 Never use the same pair of gloves to care for more than one patient. Change gloves and perform
hand hygiene between caring for two different patients.
 Change gloves when moving from a dirty area to a clean area on the same patient (example:
when cleaning a patient's perineum area, change gloves before caring for the patient's IV catheter).
 Remember: germs can be transferred with gloves just as easily as on the hands. After putting on
gloves to care for a patient, avoid touching other patients, their surroundings, or “shared patient
areas”, such as the medication station or the nurses' station.
 Glove use does not replace the need for hand hygiene. Hands must be washed with soap and
water or cleaned with hand gel before putting on gloves and after removing gloves.
 Never wash or disinfect gloves.

Remove gloves quickly, before touching non- contaminated items and

environmental surfaces in the ICU. Never walk around, answer phones or write
notes with gloves on.”

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Gowns
 When you think you will be handling large amounts of blood, excreta or secretions, put on a
protective gown for self-protection and to prevent the risk of infection to other patients. Change
gowns when the procedures are finished.

Masks and Eye protection

 Wear a mask and eye protection when there is a possibility of being exposed to splashes of body
fluids, such as during suctioning.
 Wear a mask for procedures where strict asepsis should be maintained (lumbar puncture or
dressing change).

Used personal protective equipment (PPE) should be treated as contaminated and

should not be taken out of the workplace into non-clinical areas, except during
patient transport. Remove soiled PPE as quickly as possible

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 Communication with patients & families

Communication within the healthcare team and clinical

handover
What is it? Why is it important?
Clinical handover is one type of communication, and it involves both the giving of information about
the patient to another member of the team, and also handing over the responsibility for the patient
from one doctor to another.

Effective communication, including clinical handover, is essential for providing safe and effective
healthcare for patients. If we give or receive information about the patient that is inaccurate, if we fail
to give important information at the right time, in the right way, the consequences for the patient can
be very serious, even fatal. Approximately 80% of medical errors are caused by some form of
miscommunication.

To avoid serious medical mistakes and to give the best quality of care possible, we need to make sure
that the information we give (both written and verbal) is:
 Accurate (check with the patient, look at the patient record or other documentation)
 Relevant (avoid extra information that is not necessary to the situation. Recognize when a
situation is urgent and needs immediate management)
 Organized (using a planned approach helps to save time and avoid some information not being
given).

The first step is to think about when the information will be given and to who.

When and who?

 Changing of shifts from one team to another (example: nursing shift handover, doctor changing
shift)
 Group handover (at the beginning of shifts to provide an overall view of the unit. Example: nurse
shift-leader report)
 Admission and discharge of patients including transferring to another health centre or another
department within the hospital
 Meal or break relief (example: nurse-to-nurse)
 Updating a fellow health professional on a change in clinical condition (example: between a nurse
and a doctor)

After we know our audience and our situation, then we can start to think about how we will give the
message. All of the above situations may require a different approach when giving a clinical handover.
For example, a nurse-to-nurse shift report will usually be much longer and more comprehensive than
an update to a doctor on a patient’s condition. The update on the patient’s condition needs a quick,
well-organized communication of just the facts that are relevant to the situation.

How?
Shift change handover: because this involves the transfer of responsibility, for longer periods of time,
this handover must be organized to cover all areas and avoid leaving out any relevant information.

An approach that works well includes a head-to-toe assessment of body systems. An example of this
can be broken down into the following areas:
 Identifying the patient
 Reason for admission
 Diagnosis
 Past medical history, including current medications and allergies
 Hospital course, or the main events and interventions during a patient's hospital stay
 Social history
 Neurological system, including pain control and sedation
 Cardiovascular system

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 Respiratory system
 Gastrointestinal system
 Renal system
 Skin
 IV access
 Relevant test results and laboratory values, particularly if abnormal
 Currently infusing fluids and medications, with accurate rates/doses and up-to-date documentation
in the patient record
 Other clinically relevant information, including a patient plan

Remember, be accurate! When giving a face-to-face shift report, use the patient’s records to cross-
check information such as medication charts and medical orders. Also, make sure that the information
you give in a shift report is supported by your documentation, such as progress or clinical notes and
correctly filled out flow charts and other forms of documentation.

The approach described above is an organised way of giving a thorough and understandable clinical
handover for a patient who is stable (not actively deteriorating). Is it the right approach in all
situations? No! A narrative (more detailed, like a story) approach like this is very good for making sure
you remember all the important details of the patient's history, but it is not suitable in a situation when
just the important facts are needed. In a situation that requires a quick communication and response,
there are a number of easy to use tools: SBAR, ISBAR, ISOBAR. Although there are minor differences
between these tools they are all designed for quick but effective communication. This helps the person
you are talking to understand what is needed.

SBAR
One of the difficulties in giving patient information is that verbal communication is often not perfect.
This is because most people only concentrate for a few minutes and then stop paying attention.
Because of this, it is important to give all relevant information, but only relevant information.

Also, be aware that verbal communication becomes even more difficult when given over the telephone.
This is because:
 The person you are speaking to may be distracted
 The connection may be lost before you have finished speaking
 You do not know where the other person is
To overcome these challenges, it is very helpful to use a system like SBAR. This tool is designed for
quick but effective communication and helps the person you are talking to understand what is needed.
Get the important points across in the shortest time. In order to do this it is important to ask yourself:
what does the other person need to know in order to help the patient?

The SBAR system involves providing the information under 4 headings:

Situation
Give a brief (5-10 sec) introduction to what you are calling about.

Background
Give information relevant to the problem including history and clinical findings.

Assessment
Say what you think the problem is (an exact diagnosis is not necessary but give an indication of how
severe the problem is). Just give the facts, using clinical signs, vitals signs, biological signs if available.

Recommendation
Say what you think needs to be done for the patient and if appropriate find out how long it will be
before the person will come to see the patient. Knowing approximately how long it will be before the
person will be able to come to see the patient is important as you do not want to slow down the person
you are calling by repeated unnecessary phone calls, but you do want to make sure that they have not
been side tracked or forgotten to respond. eg: Please could you come to see the patient? How soon
do you think you will be here? Would you like me to check the haemoglobin while you are coming?

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In an emergency situation
In situations that require urgent attention – do NOT provide information that is not relevant. Only give
the most important facts that are needed to give the doctor enough information to make an accurate
decision. Remember, ask yourself: What does the person I am talking to need to know in order to help
the patient (Figure 1)?

Figure 1. Think what the person you are calling needs to know

The following comic strips illustrate how communication can be improved by the SBAR system in an
urgent situation. The case is one of a patient who was admitted with pneumonia but has developed
ischaemic chest pain and acute pulmonary oedema.

In the first example (figure 2) the caller failed to convey the urgency of the situation to the doctor. A
story-telling style of communication was used with the nurse telling the doctor the time sequence of
events. Unfortunately before the nurse got to the important information the doctor was interrupted and
finished the call. No time frame was agreed on for the doctor to see the patient, with the result that
doctor and nurse had different understandings of how soon the doctor would see the patient.

The second strip (figure 3) shows how using an urgent communication tool would have been more
effective. The nurse starts with identifying himself, describes the situation in a few words, then gives
the background to the situation and an assessment. Finally he gives a recommendation (in the form of
a request to see the patient urgently) which includes a timeframe.

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Figure 2. Failure to convey the message

Figure 3. Message successfully delivered

Finally, make sure that the person you have handed over to understands the information you have
given, has had all their questions answered and takes responsibility for the patient.

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Call-out
Verbal communication becomes even more difficult but even more important in an emergency when
the chances and consequences of a mistake are even greater. Two methods may be helpful: call out
and check back.
Call-out is designed to:
 Inform all team members at the same time during emergency situations
 Help team members to predict the next steps and work more effectively as a team.
Important information about the patient is spoken out loud so that all team members can hear. An
example is given in Figure 4. Only information that is important for the whole group should be called
out.

Figure 4. Call out

Check back
In emergency situations it is often necessary to rely on verbal rather than written instructions. While
this is necessary to make sure treatment is given on time, it carries a greater risk of harm due to an
error. It is therefore important to take steps to make sure the communication is effective.

An example of ineffective communication is given in Figure 5, when the patient is accidentally given
bupivicaine (marcaine) rather than naloxone (narcan).This sort of error can be reduced by closed loop
communication in which the instruction or information is repeated back (check back).

Instead of giving the task of getting naloxone to a particular team member, the doctor just shouts out
an instruction. This carries the risk that more than one team member goes to carry out the instruction,
reducing the efficiency of the team or that no one carries out the instruction. The team leader should
make it clear who he is giving the task to, preferably by calling them by name (Figure 6). The person
being spoken to should confirm they have heard the instruction by repeating it back to the leader
(check back). This allows the leader to correct any misunderstanding.

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Figure 5. Medication error occurring as a result of poor communication

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 Communication with patients & families

Figure 6. In the first panel the doctor fails to identify who should get the Narcan. Clearly identify the person you are giving the
task to. That person should check back. Check back allows the misunderstanding to be corrected

Similarly when the task has been completed this should be clearly communicated to the team leader.
Be clear about what task has been completed.

Figure 8. In the left hand panel the nurse does not communicate well. She should tell the doctor what drug she has brought

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Communication with patients and families

Communication is essential in providing safe and effective health care to the intensive care patient. It
is an important part of our day to day work and occurs on a variety of levels. Communication with
patients and their families is as importantant as communicating with the multi disciplinary team and
can be done in a variety of ways depending on the situation.
The ICU environment is high-pressured and fast paced. For patients and families, entering this
environment, it can be extremely frightening and intimidating (Figure 1). As someone supporting the
patient and family, it is our responsibility as nurses to protect these vulnerable people and get them
used to the intensive care environment as quickly as possible.

Figure 1. Intensive care can be a frightening and intimidating environment for patients’ families

It is extremely important to welcome your patients and their relatives and friends by being
approachable and friendly. When you meet the patient for the first time, introduce yourself and let
them and their family know that you are the nurse who will be looking after their family member.
(Figure 2b).

Figure 2a A bad way to welcome a family. Figure 2b. A friendly welcome and introduction are really important.

This will make them feel more relaxed and confident that you are a person they can speak to about
any questions or concerned they may have. Be very aware of your body language and try to avoid
negative signs. Closed off body language (such as arms crossed (Figure 3) or not looking at someone

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when you are speaking to them) could be seen as negative communication which could increase
anxiety and worry in patients and their families. Speaking in a calm but confident manner not only
shows your ability to manage the intensive care situation, but will also help to avoid the patient or
family misunderstanding and thinking something is wrong.
Another part of communicating with families and the patient himself, is keeping them informed and
providing support. This can be very frightening for a young nurse so it is important to get help and
advice from more senior nursing and medical staff. This will not only reassure and inform the patient
and their family on their clinical condition but also provides an excellent opportunity for the less
experienced nurse to watch how this information is given.
Here are a few useful points to providing effective communication to your patient and their family.

Recognising your limitations

In some situations, it is okay to tell your patient or their family that you are not the best person to
speak to about the information they need and that you will seek out the appropriate health professional
to discuss this with them.

Nonverbal communication
Verbal communication is not needed in certain situations in the intensive care unit. It is important to
recognise when it is the right time to talk and when the patient and their families need their time to take
in and understand information. These signs can often be subtle and the skills for managing this are
developed over time. Some particular situations, such as those with patients who are nearing death or
are critically ill, should allow time for people to be with each other as a family. When possible, allow
privacy for the patient and their families by closing the patient’s curtains (only if it is clinically safe to do
so), or offering the patient’s relatives a quiet area, and let them know that you are there should they
need anything from you.

Providing opportunities for questions and feedback

Being given too much information is a problem often spoken about by patients and their families when
in the intensive care unit. For the non-medical person, the constant use of medical language and the
unfamiliar surroundings can lead to them feeling really confused and anxious. When communicating
with your patients and families, be aware of giving them time to take in and understand the information
you have given them. Sometimes this information may need to be repeated and non-medical terms
used to improve understanding. Reassure your patient and their family that it is normal to ask
questions in this environment and that either you yourself or the most suitable health professional will
be happy to help answer these questions for them.

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Palliative care
Many patients with critical illness will die. It is essential to maintain their comfort and dignity and support the
family through this time. Palliative care does not aim to lengthen or shorten the patient’s life but to improve
the quality of the life left to the patient with an incurable illness.
It uses a holistic approach to help relieve suffering and to support the whole person, not only the disease
process. This holistic approach to care centers on both the patient and their families, and focuses on four
aspects of care:
 Psychological care - i.e. worry, fear, anger
 Spiritual care - i.e. questions of life & death, religious support
 Physical care - i.e. symptoms; pain, constipation, nausea
 Social care - i.e. work, family, housing

Doctor and nurses decide together that no treatment is available and decide to switch to comfort care.
Nurses play an important role in improving the palliative patient’s quality of life, by recognizing opportunities
for intervention, and providing nursing care that support both the patient and their families.

It is vital for both healthcare workers and relatives to understand that a change to palliative care is NOT an
end of care. High quality care will continue to be given, but the focus of care has changed. In palliative care
our only concern is the comfort of the patient, prolonging life is no longer important. Only actions that
increase comfort should be carried out.

There are many symptoms that a palliative care patient can experience. These symptoms can be a result of
their illness or can be from the treatments used to treat their illness.
The aim of symptom management is to prevent or treat the symptoms, side effects caused by treatment and
the psychological, spiritual and social effects related to the illness.
The nurse should assess the presence and severity of each patient’s symptoms individually, however
common symptoms at the end of life include pain, dyspnea, nausea & vomiting, anxiety, depression &
constipation.

Pain
Pain is a common symptom in the palliative patient, and regular assessment and actions to prevent or treat it
should be a priority (refer to Pain chapter). In order to control pain, analgesia needs to be given regularly and
the nurse should not wait until the patient has pain before giving painkillers. It is difficult to manage pain that
has been allowed to build up.
Both pharmacological and non-pharmacological treatments can be used to help alleviate pain.

Nursing Care
 Position the patient comfortably
 Make sure painkillers are being taken regularly
 Try massage or rocking
 Hot or cold compresses
 Use of prayer or other religious practices
 Use of distraction methods; ie music

Breathlessness
Dyspnoea is common in patients with an incurable illness, and can be extremely distressing for the patient
and their families. The feeling of being unable to breathe properly can cause the patient to feel like they are
suffocating and can cause panic and anxiety. This fear and anxiety can cause the dyspnea to worsen,
beginning a cycle that is increasingly difficult to manage.
Common pharmacological interventions for dyspnea include the use of:
 Oxygen
 Bronchodilators
 Steroids
 Anti anxiety medications
 Opioids
 Diuretics

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Nursing Care
 Positioning, help the patient to sit in the best position using pillows for support.
 Fresh air, open windows or using fans to blow air gently across the face.
 Keep cool and comfortable.
 Hydration, give the patient water frequently to help thin or loosen sputum.
 Manage anxiety (refer to Anxiety section)

Nausea & Vomiting

Nausea and vomiting can be frustrating and exhausting for the patient and their family. It is also very
common in patients with advanced illness and those nearing the end of their life.
In this situation, important causes of nausea and vomiting are:
 Constipation
 Emotional factors - extreme anxiety, fear.
 Treatment related factors - medication side effects.
 Vestibular factors - dizziness
It is important to find out the cause of the nausea so it can be managed properly.
Drug treatment of nausea and vomiting can include the use of anti emetics or anti nausea drugs, such as
metoclopramide, chlorpromazine and ondansetron.

Nursing Care
 Avoid things that trigger the nausea, such as cooking or food smells, sights or sounds near the patient.
 Look at medications to see if they may be causing the nausea/vomiting.
 Try to relieve the nausea using behavioral approaches, such as relaxation, distraction techniques &
massage.
 Offer drinks and food that the patient likes in very small and frequent portions that may be better
tolerated.
 Give oral rehydration sachets if available.
 Boiled or chewed ginger may help
 If nothing can be done to relieve the symptoms, then it is important to position a patient in a way that will
stop them from aspirating if they vomit.

Anxiety
Patients who have an incurable illness and their families, are often anxious. This anxiety can increase as the
patient and their family become aware that the illness is getting worse and they are not expected to live
much longer. They may have unpleasant thoughts, including fear of pain, death and becoming dependent on
others.
Anxiety can be due to a number of causes:
 Physical - difficulty breathing, pain
 Psychological - sadness, fear
 Social - worry about care of children, finances
 Spiritual - life & death questions

Nursing Care
 Flexible visiting hours
 Psychological support
 Make sure the patient receives good health care and medical support
 Help with practical matters; e.g. arranging childcare, household support
 Arrange for them to see someone who they can talk to about their spiritual needs.
 Take time to listen to the patient and provide emotional support.
For severe anxiety and agitation that does not respond to non drug treatment, medication may be prescribed
to help (e.g benzodiazepines, haloperidol)

Depression
Sadness and depression are common and often expected emotions in patients with an incurable illness.
Signs and symptoms of depression such as weight loss, reduced energy, reduced appetite, and
sleeplessness can also be caused by the illness itself, making depression difficult to diagnose in the
palliative patient.

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Nursing Care
 Make sure the patient is as comfortable as possible
 Make sure symptoms are being managed as well as possible.
 If the patient has a religious faith, then visits from the patient’s religious faith group may help
 Listen to the patient and try to find out what is making them feel sad
 Talk to the patient about their disease and explain to them what is happening.

Constipation
Constipation is the difficult, painful or infrequent passing of hard stools, and is very common in the palliative
patient. Prevention of constipation is important as it can cause severe discomfort and distress and can be
difficult to relieve. There are many causes for constipation and it is important to find out the cause so the
correct treatment can be given.
Possible causes include:
 Dehydration
 Poor diet
 Immobility
 Medications; such as morphine (however, it has to be given if needed)
 Intestinal obstruction
As the patient approaches the end of their life, they may pass very little stool due to their poor oral intake. In
this case the constipation does not need treatment. However if constipation is suspected, a thorough
assessment, including a rectal examination to look for stool in the lower colon, may be needed.

Nursing Care
 Encourage oral fluids
 Increase fibre in the diet
 Laxatives/local remedies
 If the stool is hard and painful to pass, the insertion of petroleum jelly (Vaseline) into the anus may help
in passing the stool
 Give a teaspoon of vegetable oil orally in the morning
 If there is stool in the rectum, and the patient cannot pass it, a manual evacuation may be needed.
Manual Evacuation
 Explain the procedure to the patient
 Give some analgesia if available
 Prepare sheets or paper to receive the stool once it has passed
 Put on gloves
 Lubricate the finger with lubricant or petroleum jelly
 Insert the finger slowly to help the muscles to relax
 Remove small pieces of stool, one at a time
 Reassure patient throughout the procedure and stop if too uncomfortable

Rash/Itching skin
Skin problems and rashes are common in some palliative patients, and can be a cause of discomfort,
irritation and embarrassment.

Nursing care
 Avoid washing with soap, use another type of cleanser if available
 Apply moisturizer or petroleum jelly to dry skin
 Use a cool fan on the affected skin
 Try washing with sodium bicarbonate in water solution (1TBSP in a bowl) to relieve itch
 Keep the patient’s fingernails short if they continue to scratch
 Use warm or cool water, not hot.

Sore mouth/swallowing difficulty

A sore, infected, or ulcerated mouth is common in the palliative patient and can be very distressing. Many
mouth problems can be prevented by good mouth care: keeping the mouth clean and moistened.

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Nursing Care
 Check the mouth, gums, teeth and tongue regularly
 Brush teeth with a soft toothbrush twice a day or after eating
 If mouth is sore, use a wet, soft gauze wrapped around the finger to clean and moisten the mouth
 Moisten mouth with regular sips of water
 Use petroleum jelly on lips
 Suck pieces of fruit
 Use a mouthwash made of 1 cup of boiled (cooled) water and a pinch of salt or teaspoon of lemon juice

Seizures
Seizures can be frightening for the patient and very distressing for the family if they see the attack. It is
important to teach the patient and the family about the seizures and how to keep the patient safe throughout
the attack (Refer to Neurological chapter)

Address any concerns regarding the spiritual significance of the seizures

Immobility
If the patient cannot move on their own, they are at risk of pressure sores or bedsores.(refer to Prevention of
complications from immobility chapter). These sores can be prevented by regular pressure area care. If the
patient is unable to move their limbs then they can stiffen and contract. Regular passive movements of the
joints can help to decrease the severity of this. Involve the physiotherapist and the family can also be asked
to help with exercises.

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 Triage

Appendix 1 – triage

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BASIC DHS for Nurses

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 Oxygen cylinders

Appendix 2 – oxygen cylinders

Table of duration of oxygen supply based on pressure

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BASIC DHS for Nurses

Appendix 3 – post partum haemorrhage

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