ROLE OF THE NURSE IN LIFE-THREATENING 3.

Effective decision making

4. Appropriate staffing
SITUATIONS
5. Meaningful recognition
Critical Care Nursing
6. Authentic leadership
“ a specialty within nursing which deals specifically with
human responses to life- threatening problems” (e.g.
The Critical Care Nurse
trauma, surgery)
- Greater clinical expertise and maturity
- AACCN
- Critical thinking ability
- Assertiveness
Scope of Critical Care Nursing
- Client management skills (medical- surgical)
- Genuine, humane, compassionate attitude
- Intelligent decision- making/ autonomous
- Coordinator of the health care team

The nurse…
- Health related goals to regain or maintain biological
Critically Ill Patient
patient’s who are at risk for actual or potential and psychological wellness. This may include ensuring a
life-threatening health problems peaceful death.
-Has understanding of ethical or legal principles to
Critical Care Nurse protect nurses from lawsuits.
-a nurse who practices in settings where patients require
complex assessment, high- intensity therapies and ETHICAL PRINCIPLES
interventions, and continuous nursing vigilance 1. Autonomy
2. Beneficence
Critical Care Environment 3. Non-maleficence
- equipped with monitoring devices for intensive patient 4. Veracity
care and monitoring LEGAL ISSUES
(mechanical ventilation, cardiac monitor, suction machine, 1. Negligence
defibrillator) 2. Malpractice
3. Right to Accept and Refuse
The Critical Care Environment Medical Treatment (Advance Directives)
- F. Nightingale – developed the idea of clustering the 4. DNR orders
most acutely ill patients in the 1800s during the Crimean
War - Cares for patients and families
- 1900s – Johns Hopkins Hospital; 3 bed post-op - In depth knowledge in Anatomy and Physiology,
neurosurgical ICU pathology, advanced assessment and advanced
- 1940-1944 – World War II; establishment of shock wards biotechnology
for injured soldiers - Use of TOTAL CARE MODEL
- 1945 – clustering of patients was done due nurse - The critical care patient
shortage Reasons for admission to ICU:
- 1950s – polio victims were cared for in specialized units 1. Physiologically unstable
- 1960s – ECGs, arterial and CVPs; Coronary care units for 2. At risk for serious complications
MI patients were developed; establishment of recovery 3. Requires intensive and complicated
rooms nursing support (use of IV drugs and advance medical
- 1970s – ICUs became standard units globally; New: technology)
Progressive Care Units (PCUs or step down units) Common Problems of CC patients
1. Nutrition
- Developments: creation of Rapid Response Teams (RRT) in
2. Anxiety
in hospitals; has three members (CCN, RT, CCP or APN)
3. Pain
4. Impaired communication
ACCN standards: Healthy work environment
1. Skilled communication 5. Sensory perceptual problems
2. True Collaboration 6. Sleep problems
Emergency Care Management A. Systematic approach for goals and objectives
(goal setting requires cooperation among health
care personnel) - ED’s overall philosophy: “provide
optimal emergency care”
- writing objectives helps determine the cause of
the deficiency and assist the resolution
- formulate a task outline (listing of specific
activities)
B. Problem Identification and Resolution
- a simple mechanism for differentiating symptoms
from diseases and identifying system problems is
to follow statements about problems with
I. HISTORY
because
Emergency Nursing – refers to any extraordinary event
- Example: Morale is low because.... Patients are
that requires rapid and skilled response that can be
leaving because.....
managed by a community’s existing resources (e.g. train
Charting is inadequate because....
crash, earthquake)
- when resolving problems, take care not to
Disaster – a manmade or natural event that overwhelms a
overtreat or undertreat the disease
community’s ability to respond with existing resources
Example (overtreatment):
Disasters result in mass casualties (>100 victims),
a CBC, urinalysis, blood sugar, blood
physical and emotional suffering, and permanent changes
gases, electrolytes, radiographs, and lung scan on an
within the community
emotionally upset patient with rapid RR, numbness, and
Emergency services – organizations that ensure public
tingling which can be relieved by paper bag breathing
safety and health by addressing different emergencies
(costly & time-consuming overtreatment)
- engage in community awareness and prevention
Example (undertreatment): a patient with sudden onset of
programs to help the public avoid, detect, and report
headache and no prior history should not be sent home
emergencies effectively
w/out a neurologic exam
EMS – Emergency Medical Services
- EMS system; provides “prehospital” or “out of hospital”
C. Administrative structure – assignment of
care
responsibilities for people and functions
Purpose: to get trained personnel to the patient as quickly
- each staff has defined areas of responsibility -
as possible and to provide emergency care on the scene,
appropriate method for operating a department
en route to the hospital, and at the hospital
include identification of needs, creativity, and
EMT-B (Emergency Medical Technician-Basic) - is a key
matching people with functions
member of the EMS team
D. Management of people
II. EMERGENCY NURSING
- placing the right people in a good system and
Scope of Emergency Nursing Practice
managing them effectively; motivation is
Qualifications of an ER Nurse
necessary to people management (communication,
Certification: to assure the public that an individual has
staff involvement)
acquired a specific body of knowledge
- Scheduling: create a staffing plan that meet the
Certification can be obtained through:
flow of ED volume – since emergency care is
- state or government agency (nurse
stressful mentally, physically, and emotionally
certification; continuing education program) - institution
- Performance appraisal – done in a positive and
(health care facility); completion of educational offering,
constructive manner
e.g. local triage, trauma nursing, mobile intensive care
- professional organization (PNA)
2. PATIENT EDUCATION
- Documentation of patient teaching is mandated by both
Roles of an ER Nurse
quality improvement and accreditation criteria
1. MANAGEMENT
- increase in the variety and sophistication of educational
- an ED manager must utilize strong organizational skills,
materials
effective IPR skills, and sound financial principles
- Factors include: fear of litigation, and cost containment
- an organization has a system of performance
- patient’s right to be informed of procedures - knowledge
of home care is important since it reduces number of
return visits
3. RESEARCH
- goal of nursing research: to facilitate
development of clinical nursing interventions that
improve health outcomes and contribute to optimal health
care delivery
- outcome of research: validated solutions to health care
problems are implemented/ improved health/
cost-effective care
Emergency Nursing Environment
- Unplanned situations that require intervention
- Allocation of limited resources
- Need for immediate nursing care
- Unpredictable number of patients
- Geographic variables
- Unknown patient severity, urgency, and
diagnosis
Principles of Emergency Care
1. COMMUNICATING IN CRISIS
- an ED nurse’s behavior, communication
and inability to make decisions will reflect her anxiety
a. Recognizing feelings
- validate the patient’s feelings
- never belittle or criticize feelings
- diminishes therapeutic communication
- do not assume patient’s feelings
b. The need for therapeutic communication
- first encounter a person has with emergency
personnel will set the tone for the entire
experience
- if invasive procedures are to be performed stat
(verbal communication must be used)
- patient should know the reason for the
intervention, risks, or pain
c. Communication techniques
C.1. Support
c.2. Silence – allowing participants to pause and
reflect and think what is
being asked or said
c.3. Listening – more important than the
ability to speak
c.4. Questions – can stabilize a crisis, be
helpful and decreases powerlessness
Non helpful questions:
1. Leading question e.g. “why would you ever skip
your medications?”
2. No-choice question e.g. “you’re ready for your
x-ray, aren’t you?”
3. Double question e.g. “do you want something for
pain? are you allergic to morphine?”
Helpful questions:
1. Limited choice questions e.g. “do you want this
injection in your hip or arm?
2. Open-ended question e.g. “what made you come
to the hospital today?”
3. Closed question e.g. “do you have headache,
nausea...?
4. Sensitive question e.g. is there any more
information that may have been left out, which I
may need to know, to best help your loved one?
DONT’s in Questioning
- don’t ask too many questions
- don’t ask “why” questions
- don’t ask double questions
- don’t ask long, elaborate questions
D. Special Communication Situations
d.1. Children
- consistent, calm approach
- be familiar with G/D patterns
d.2. Victims of trauma
- gentle, calm repetition and explanation to
organize their thoughts
d.3. Very anxious patients
- use short, simple, direct, and repetitive phrases
- give meaningful important info
d.4. hearing-impaired patients
- speak in lower tone, face to face - find a quiet
room; write the questions
d.5. non-English-speaking patients
- hospitals are required to provide a trained
interpreter (Medicaid)
Communicating with Survivors when a sudden death
occurs:
- Reach out to family and friends of victim
- Staff personnel as resource persons (provide
empathic listening, support, information,
and direction
- Anticipate families’ needs
- Additional support (chaplain, psychiatric
clinical nurse specialist, social worker)
- Give opportunity be see the deceased
Bereavement, Assessment, and Intervention:
- As soon as death is imminent or condition is
deteriorating, member of emergency team should
contact the family
 - If patient is not doing well, be honest and inform
family specifically
- Listen to family; be aware of their body language
and non-verbal communication; ask open-ended
questions
- Assess religious beliefs
- Ask for organ donation
- Encourage release of emotions; avoid giving
medications
- If autopsy is necessary, help family understand
the role of the medical examiner
- Contacting funeral home
2. PATIENT ASSESSMENT, REPORTING, AND DOCUMENTATION
a. Steps in assessment
1) Primary survey
2) Secondary survey
- Pain assessment – PQRST
b. Documentation
- obtain patient info
- document findings
- if unable to assess a certain parameter
(BP), state the reason
3. PATIENT AND FAMILY EDUCATION
- to ensure adherence to prescribed therapeutic and
preventive measures; provide individualized home care
instruction; knowledge of home care is a patient’s
right
4. BASIC LIFE SUPPORT
- more people die from MI w/in the first 2 hours of
the infarction; training programs improved the
survival rate of out of hospital MI
- consists of recognizing unconsciousness, opening
the airway, maintaining the airway
- check for carotid pulse
5. ADVANCED LIFE SUPPORT
- for sudden cardiac death that occurs w/in 1 hour
of the onset of symptoms due to CAD;
- majority of patients experience V tach, which
degenerates into V fib
- victim can survive neurologically if CPR is
delivered w/in 4 minutes and defibrillation is
done w/in 10 minutes
6. INTRAVENOUS THERAPY
- IV line is initiated so that fluids, meds, blood,
and blood products can be replaced into the
vascular circulation
a) Dextrose solutions (D5%W and D10%)
- main way of providing calories in fluid
administration
Uses: KVO IV lines; non electrolyte hydration
Precautions:
- not in the same IV line w/blood
- may increase ICP in head injuries
b) Sodium containing IV solutions (0.45% NS & 0.9%
NS)
Uses: restoration of water & salt loss in
hypovolemic shock and dehydration;
administration w/ blood products & meds; for
metabolic alkalosis
Precautions:
- sodium retention; large infusions can lead to
acidosis and circulatory overload
c) Multiple electrolyte solutions (Ringer’s, Lactated
Ringer’s)
Uses:
- replacement of ECF losses - severe shock
- cardiac arrest
Precautions:
- excess may cause overhydration
- electrolyte excess (sodium)
- cardiac or renal disorders
- contraindicated in hepatic disorders
7. LABORATORY SPECIMENS
7.1. tubes for drawing blood
Red top (no preservative or anticoagulants) – for
serologies, chemistry panels
Lavender top (w/ ethylenediaminetetraacetate) – for
hematology, lipoprotein, phosphatase
Blue top (w/ sodium citrate)–coagulation studies Gray top
(w/ sodium flouride) – blood glucose,blood alcohol, drug
tests
Green top (w/ sodium heparin) – special procedures
7.2. Specific tests
a. CBC – 5 ml required
b. Urinalysis – examined w/in 30 mins
c. Blood glucose – obtained as clot specimen;
collected before starting IV; 2-3 ml
d. BUN – measures circulating urea in the blood; 1
ml
e. Serum electrolytes
f. Serum creatinine – evaluates renal functions;
elevated in ARF; 3 ml
g. Cardiac enzymes (CK-MB, Trop T) – 5 ml - dx of MI
h. Serum drug level – specific to a drug, like
digoxin; 2-5 ml
 i. Serum amylase – a digestive enzyme for
carbohydrates; increased in acute pancreatitis; 3
ml
j. ABGs –acid-base status; 3 ml
k. WBCs and differential count – 3-5 ml
l. Coagulation studies – evaluates different stages of
clotting
1) Prothrombin time – measures formation of a
fibrin clot
2) Partial thromboplastin time – measures the
clotting time of plasma
3) Platelet count
4) Clotting time – measures the time it takes for a
fibrin clot to form in venous blood
5) Bleeding time
M. Spinal fluid – 3-5 specimens; spinal tap
N. Urine specimens – through MSCC
O. Stool specimens – for stool cultures, it should be warm
and newly evacuate; in a sterile container; do not add
saline since it may destroy parasites
8. SHOCK & HEMODYNAMIC MONITORING
Shock is a complex syndrome that develops: - due to
inadequate or inappropriate tissue perfusion
- inability of tissues to utilize available oxygen &
nutrients
- leading to cellular hypoxia & buildup of toxic
metabolites, which
- results in tissue damage and organ dysfunction
Types of shock: Hypovolemic, Cardiogenic, Septic,
Anaphylactic, Neurogenic, Obstructive
Goal of Interventions: to restore and maintain adequate
delivery of oxygen and nutrients by preventing or
reversing anaerobic metabolism
Hemodynamic monitoring
- optimizes the successful management of shock
- hemodynamic status can be assessed by:
1. Non-invasive methods (BP, V/S, urine output,
mental status
2. Invasive methods (PAP, CVP)
*SIDE NOTES
- Many laws affect emergency nursing practice
(Constitution; Bill of Rights)
- The Free exercise clause of the First Amendment
affects refusal of care for religious reasons
- Right to privacy includes the right to refuse
treatment
- Protections against search & seizure of criminal
defendants affect the ED when the police requests
collection of evidence
1. CONSENT:
3 Types:
a. Expressed – given by adults who are of legal age and
mentally competent
b. Implied – in an unconscious patient, consent may be
assumed
c. Consent to treat minors/incompetent patients
- parents & guardians have the legal authority to give
consent
2. REFUSAL OF TREATMENT
- due to denial, fear, failing to understand
the seriousness of the situation, intoxication
Steps to be undertaken :
- Pt must be legally able to consent
- Pt must be mentally competent & oriented
- Pt must be fully informed
- Pt must sign a “release” form
Actions to persuade a patient to accept care:
- Spend time speaking to the patient
- Inform patient of the consequences
- Consult medical direction – doctor speaks to patient
- Contact family members to help convince the patient
- Call law enforcement personnel if necessary
- Determine why the patient is refusing care
3. DO NOT RESUSCITATE ORDERS
- a legal document signed by the patient and his doctor,
which states that the patient has a terminal illness and
does not wish to prolong life through resuscitative efforts
- called an Advance Directive
4. NEGLIGENCE – finding of failure to act properly in a
situation in w/c there was a duty to act;
- needed care which is reasonably expected from the
EMT-B was not provided, and harm was caused to the
patient as a result
Example: leaving a patient without making sure that the
patient has been turned to someone with medical training
results in abandonment
5. GOOD SAMARITAN LAWS
- designed to provide limited legal protection to citizens
and health care personnel when they are administering
emergency care
- provide immunity to individuals who help people during
emergencies; Licensing & Certification requirements
6. CONFIDENTIALITY
- obligation not to reveal information
obtained about a patient
Exceptions:
- info given to other health care personnel involved in
patient’s care
- under subpoena; court of law
- patient signs a release of confidentiality
HIPAA (Health Insurance Portability and Accountability
Act)
- a law protecting the privacy of patient health
care information
- ambulance services are mandated to have
policies, procedures and training to deal with
privacy issues
7. MEDICAL IDENTIFICATION DEVICE
- worn to alert health-care professionals that the patient
has particular medical condition; necklace, bracelet, card
- if patient is unconscious, the device provides important
medical information
- for heart diseases, allergies, diabetes, epilepsy
8. ORGAN DONATION
- patient needs to have a completed legal document that
allows for donation of organs and tissues in the event of
his death
- patient may have organ donor card (back of driver’s
license may contain an indication that patient wishes to
donate organs upon his death)
NOTE: all emergency care measures must be taken
9. SPECIAL CRIMES AND REPORTING
- reporting crimes (child, elderly or domestic abuse)
- failure to report may be a crime
- violence such as gunshot wounds, stabbings, and sexual
assaults
- notify police in cases where restraints may be necessary,
intoxicated persons found with injuries, or mentally ill
people
10. MEDICAL RECORDS
- hospital has the right to control the record, but patients
generally have the right to information on the record
- release of information without consent from the patient
can lead to criminal and civil liabilities
11. RIGHT–TO-DIE CASES
- Patient Self-determination Act of 1990
- hospitals are required to ask patients during admission
if they have an Advance directive
- Advance directive (living will, durable power of attorney
for health care)
Techniques for ensuring an AD:
a) permanent armbands
b) laminated pocket-size copy of the AD
c) medical record contains AD
12. EMERGENCY MEDICAL TREATMENT AND ACTIVE LABOR ACT
(EMTALA)
- Former name COBRA (Consolidated Omnibus
Reconciliation Act)
- a law passed to address patient dumping (transfer
of unstable patients for financial reasons)
- All individuals arriving at the ED for examination
& treatment are entitled to an appropriate
Medical Screening to determine if an emergency
medical condition exists
Medical Screening – application of the same procedure to
paying & indigent patients
- Hospital with specialized capabilities (trauma centers,
neonatal centers, burn units) are obligated to accept all
appropriate transfers of patients who require care if they
have the capacity to treat the individual
- Triage nurse “triages out” patients with nonurgent
complaints after initial medical screening; done after an
initial nursing assessment but before medical evaluation
- may result to an EMTALA violation if there is a medical
condition
13. PRESERVATION & COLLECTION OF EVIDENCE
- For cases of child abuse, communicable diseases,
gunshot wounds, stabbings, sexual assaults, burns,
suspicious death, animal bites, and poisoning
- As a rule, victims or perpetrators of violent crimes who
enter the ED for treatment are candidates for evidence
collection; Presence of legal counsel
14. MENTAL HEALTH PATIENTS
- A patient diagnosed with mental illness is competent
to consent to medical care unless a court determines that
legal incompetency exists
- Patients with suicidal or homicidal ideations require
immediate intervention
- Physician’s order is necessary when a patient is
restrained
Arterial Blood Gas Analysis
Arterial Blood Gas Analysis (ABG)
is a test that measures oxygen and carbon dioxide levels
in your blood. It also measures the body’s acid-base (pH)
level.
-a group of tests that are performed together to measure
the pH and the amount of oxygen (O2) and carbon dioxide
(CO2) present in a sample of blood, usually from an artery,
in order to evaluate lung function and help detect an
acid-base imbalance that could indicate a respiratory,
metabolic or kidney disorder.
Why are we checking the oxygen and carbon dioxide
levels? Acid-base level?
Acid–base homeostasis is the homeostatic regulation of
the pH of the body's extracellular fluid (ECF). The proper
balance between the acids and bases (i.e. the pH) in the
ECF is crucial for the normal physiology of the body—and
for cellular metabolism.
What is homeostasis?
Homeostasis refers to the capacity of the body to
maintain the stability of diverse internal variables, such
as temperature, acidity, and water level, in the face of
constant environmental disturbance.
From: Progress in Brain Research, 2013
Why is homeostasis regulated?
How do blood gasses behave? Hydrogen ions
move down from high to low concentration the cell
membrane, through a channel or transporter made by a
protein; This movement can be used to move additional
molecules into a cell or to add more energy to a molecule
When we think of liquid water, we picture lots of H2O
molecules moving around. Most of the water is like this,
but some of the H2O molecules dissociate, or split apart,
and become a hydrogen ion (H+), which is also called a
proton, and a hydroxide ion (OH-). The concentration of H+
in the solution is measured by pH: as H+ increases, the
solution's pH decreases. When different molecules dissolve
in the water, they can affect the number of H+ molecules
and thus affect the pH of the solution
The Carbonic-Acid-Bicarbonate Buffer in the Blood
In red blood cells, carbonic anhydrase forces the
dissociation of the acid, rendering the blood less acidic.
Two main components of the body's regulation of acids
1. involves both metabolism and the kidneys: the
cellular process of converting one substance to
another for energy produces large amounts of
acid that the kidneys help eliminate
2. involves eliminating carbon dioxide (an acid
when dissolved in blood) through exhalation of
the lungs. This respiratory component is also the
way that the body supplies oxygen to tissues. The
lungs inhale oxygen, which is then dissolved in
the blood and carried throughout the body to
tissues
These processes of gas exchange and acid/base balance
are also closely associated with the body’s electrolyte
balance. In a normal state of health, these processes are
in a dynamic balance and the blood pH is stable.
Components included in blood gas analysis: pH
pH—a measure of the balance of acids and bases in the
blood.
Increased amounts of carbon dioxide and other acids can
cause blood pH to decrease (become acidic)- ACIDOSIS
Decreased carbon dioxide or increased amounts of bases,
like bicarbonate (HCO3-), can cause blood pH to increase
(become alkaline)- ALKALOSIS
Partial pressure of O2 (PaO2)—measures the amount of
oxygen gas in the blood.
Partial pressure of CO2 (PaCO2)—measures the amount of
carbon dioxide gas in the blood.
As PaCO2 levels rise, blood pH decreases, making the
blood more acidic- ACIDOSIS
as PaCO2 decreases, pH rises, making the blood more basic
(alkaline) - ALKALOSIS
O2 saturation (O2Sat or SaO2)—the percentage of
hemoglobin that is carrying oxygen. Hemoglobin is the
protein in red blood cells that carries oxygen through
blood vessels to tissues throughout the body.
O2 content (O2CT or CaO2)—the amount of oxygen per 100
mL of blood.
Bicarbonate (HCO3–)—the main form of CO2 in the body. It
is a measurement of the metabolic component of the
acid-base balance. HCO3– is released and reabsorbed by
the kidneys in response to pH imbalances and is directly
related to the pH level. As the amount of HCO3– rises in
the blood, so does the pH (becomes alkaline).
ABG Analysis
Step I: Does paO2 show hypoxemia?
< 40 – surely compromised
PaO2 reflects 3% of total O2 in the blood.
Normal (80-100) other sources (95-100) Infant
(40-70)
Step II Is the patient on the acid or alkaline side of 7.40?
Ph – hydrogen in (H+) concentration of plasma. N
7.35 to 7.45
Acidosis – below 7.35 Alkalosis – above 7.45
This is usually the primary disorder Remember:
an acidosis or alkalosis may be present even if
the pH is in the normal range (7.35 – 7.45)
Step III. Does the PaCo2 show resp. acidosis, alkalosis or
normalcy?
- indicates whether the patient can ventilate well
enough to rid of the CO2 the body produces as by
product of metabolism.
- N= 35 to 45 mmHg.
- Above 45 PaCO – acidosis 2
- Below 35 PaCO2 - alkalosis
Is the disturbance respiratory or metabolic?
What is the relationship between the direction of change
in the pH and the direction of change in the PaCO2? In
primary respiratory disorders, the pH and PaCO2 change in
opposite directions; in metabolic disorders the pH and
PaCO2 change in the same direction
.
Step IV. Does the HCO3 slow metabolic acidosis, alkalosis
or normalcy?
- Bicarbonate is the base balance component that
reflects kidney function.
- N- 22 to 26 mEq
- <22 of bicarbonate – metabolic acidosis, renal
failure
- > 26 of bicarb – metab. alkalosis from fluid loss (
UGIT vomiting or NGT Suction ,diuretic therapy,
hypokalemia, alkali administration, or steroid
therapy.)
Step V. Is the body compensating?
- If abnormality is respiratory in nature,
bicarbonate will compensate.
- If abnormality is metabolic in nature, PCO2 will
compensate.
RESPIRATORY - the movement of the HCO3 is checked if
moving towards the opposite of being in alkaline or
acidic side
EX. Respiratory acidosis - the HCO3 must increase
Respiratory alkalosis - the HCO3 must decrease
Metabolic acidosis - the PaCO2 must decrease Metabolic
alkalosis - the PaCo2 must increase
If the movement of the other is towards the opposite of
main concern which is either alkalinity or acidity, the
body is compensating
If the other remains normal, the body is not compensating
pH -7.35- 7.45
PaCO2- 35-45 mmHg
HC03 - 22-26 mEq/L
● Fully compensated - pH is within normal range
but there are abnormalities in either of HCO3 or
PaCo2
 ● Partially compensated- pH is not within normal
range with either PaCo2 and HCO3 moving and ECG Paper
values abnormal A graph paper made up of small and larger, heavy- lined
● Uncompensated - either PaCo2 and HCo3 is normal squares.

1. pH 7.50
Pa CO2 30 mmHg
HCO3 24mEq/L
2. pH 7.2
Pa CO2 25 mmHg
HCO3 15 mEq/L
3. pH 7.26
Pa CO2 56 mmHg
HCO3 24 mEq/L
4. pH 7.62
Pa CO2 48 mmHg
HCO3 45 mEq/L
5. pH 7.44
Pa CO2 54 mmHg
HCO3 36 mEq/L

Basic ECG Interpretation

For undergraduate students Isoelectric Line
Types of Cardiac Cells 1. Positive deflection
A. Myocardial cells 2. Negative deflection
● Working or mechanical cells
● Contain contractile filaments
B. Pacemaker cells
● Specialized cells of the electrical
conduction system What Does the ECG Measure?
● For the generation and conduction of
electrical impulses

Properties of cardiac cells

Excitability
• Can respond to outside stimulus
Automaticity
• Spontaneously initiate an electrical impulse without
being stimulated from another source
Conductivity
• Can receive EI and conduct it to adjacent cardiac cell
Contractility
• Muscle contraction in response to electrical stimulus
What is an ecg rhythm?
• a visual representation of the electrical activity of the
heart
• reflected by changes in the electrical potential at the
skin surface

Purposes of ECG:
1. Evaluate the effects of systemic related diseases
2. Confirms definite diagnosis or as a differential
diagnosis (MI versus Angina)
3. To guide appropriate therapy 4. Insertion of pacemakers
Rhythm: Regular versus Irregular divided by # of large boxes from 1 Rwave to the
● Distance between the ‘R’ waves next Rwave
● Large boxes method
● Memory method
300/150/100/75/60/50

The cardiac conduction pathway

From the SA node to the Atria to the AV node to the

Ventricles
Rate Determination
● Atrial rate determination
● Vent. Rate determination
● Small boxes method: 1500 divided by # of small
boxes from 1 Rwave to the next Rwave: 300
 3. P waves: smoothly rounded, precede each QRS
complex
- At rest, usually asymptomatic
- With increased activity, persistent slow rate will
lead to symptoms of easy fatigue, SOB, dizziness
or lightheadedness, syncope, hypotension
Treatment:
● Treat only if patient is symptomatic
● Oxygen is always appropriate
Intervention sequence for bradycardia
Skin Preparation 1. Atropine 0.5 mg
● Clean skin where electrodes will be applied 2. Transcutaneous pacing if available
● Rub electrode site with alcohol
● Shave any hair from electrode site
● Improves conductivity
● Electrodes remove easier Sinus Tachycardia
● Apply electrode 1. Rhythm: regular
● Remove electrodes after use 2. Heart rate: 101 to 150
● Use adhesive remover or moist cloth may arise 3. P waves: rounded, precede each QRS complex,
from any part of the heart atria or ventricles alike
causing abnormal heart rates and activity. If rate is >150bpm it is SVT or Atrial Tachycardia
What are Ectopic foci? Pathophysiology:
- may arise from any part of the heart atria or ● more a physical sign
ventricles causing abnormal heart rates and Etiology:
activity. ● Normal exercise
Determine ECG by: ● Fever
● Configuration ● Hypovolemia
○ P, QRS, T characteristics ● Adrenergic stimulation; anxiety
● Rhythm ● Hyperthyroidism
○ Regular or irregular
● Rate
○ Speed (bpm)

Pointers: Atrial Rhythms

➢ Depolarization results to contraction
➢ Repolarization results to relaxation
Rules:
1. Treat the PATIENT and NOT the monitor.
2. Treat when patient is symptomatic.
How are Cardiac Rhythms named?
Normal Sinus Rhythm (NSR)
1. Rhythm: regular
2. Heart rate: 60 to 100 bpm
3. P waves: rounded, precede each QRS complex,
alike
Rate: above 150 bpm
Source: not SA node P waves change in appearance or are
not seen @ times
Rhythm: regular or irregular
Atrial Flutter
1. Rhythm: atrial rhythm regular; ventricular rhythm
regular or irregular depending on consistency of
AV conduction of impulses
2. Heart rate: ventricular rate varies
3. P waves: flutter or F waves with sawtooth pattern
Rhythm: regular or irregular

Rate: Atrial rate 220-350 beats/min

Sinus Bradycardia Ventricular response: A function of AV node block or
1. Rhythm: regular conduction of atrial impulses
2. Heart rate: < 60 bpm
 1st degree AV Block
Atrial Fibrillation ● Configuration: P, QRS complex and T wave seen
1. Rhythm: irregularly irregular ● Rhythm – Regular
2. Heart rate: atrial rate not measurable; ● Rate: may vary
ventricular rate under 100 is controlled PROLONGED P-R INTERVAL ( >5 small squares )
response > 100 is rapid ventricular
response
3. P waves: no identifiable P waves
P-R interval: 0.12 – 0.20 seconds
starts from P wave to start of QRS complex
● 1 small box = 0.04 seconds
Rhythm: Wide-ranging ventricular response to atrial rate ● 5 small boxes = 1 large box = 0.2 seconds
of 300-400 beats/min
P waves
● Chaotic atrial fibrillatory waves only
● Creates disturbed baseline
Junctional Rhythms
Rate: 40 – 60 bpm 2nd degree AV Block (Wenkebach)
P waves: absent, flat or depressed ● Configuration: P waves, QRS complex and T waves
Rhythm: regular seen
● Configuration: P waves FLAT, ABSENT or INVERTED, ● Rhythm – Regularly Irregular
QRS & T waves seen ● Rate: normal or slow
● Rhythm – Regular Progressive lengthening of P-R interval until a QRS
● Rate: 40 – 60 bpm complex is dropped (dropped beat)

2nd degree AV Block (Non - Wenkebach)

REVIEW:
• Configuration: P waves & QRS waves @times unpaired
• Rhythm – Regular
• Rate: normal or slow
Constant lengthened P-R interval until a QRS complex is
dropped
3rd degree AV Block
• Configuration: P waves unrelated, QRS generated by
ventricles
• Rhythm – Regular
• Rate: slow
Complete heart block: No atrial impulses pass through the
AV. So AV nodes create impulse thus the rate is junctional.

Ventricular Rhythms
Death forming arrhythmias
Premature Ventricular Contractions

Heart Blocks
Blockage is at the AV node.
Note: P wave is normal. AV nodes block impulse. Impulse
not transmitted to BofH and PF. No transmission. No Ventricular Tachycardia
depolarization. No contraction. No SV. No BP. 1. Rhythm: usually regular, may have some irregularity
2. Heart rate: 150-250 ventricular bpm; slow VT is below
150 bpm ● AICD- Automated Implantable Cardioverter
3. P waves: absent Defibrillator
4. PR interval: none Monitored Arrest
The patient is already connected to the monitor at the
time of the arrest.

Ventricular Fibrillation PRECORDIAL THUMP

1. Rhythm: chaotic and extremely irregular Perform by directly hitting the mid-sternum or center of
2. Heart rate: not measurable the sternum using the hypotenar aspect of the fist
3. P waves: none (softest side) from a height of no more than 12 inches.
4. PR interval: none
5. QRS complex: none Defibrillation
Is a delicate procedure performed by a competent RN
wherein electrical shock or shocks of short duration is/are
discharged through the heart as an attempt to terminate
death-forming dysrhythmias.
Pulseless Electrical Activity
Indications:
Cardiac conduction impulses occur in organized pattern,
- Standard treatment for Ventricular Fibrillation (VF)
but this fails to produce myocardial contraction (former
- Pulseless Ventricular Tachycardia (VT)
“electromechanical dissociation”) or insufficient
Mechanism of Action
ventricular filling during diastole or ineffective
Defibrillation involves the use of electrode paddles or
contractions
patch to deliver the electric current through the client’s
Asystole
heart.
1. Rhythm: none
How does Defibrillation work (Purpose)?
2. Heart rate: none
The purpose of the delivered current is to temporarily
3. P waves: none
depolarize critical mass of the myocardial cells when
4. PR interval: none
beating irregularly so that if successful, the non
5. QRS complex: none
ventricular pacemaker will resume the control of the
Cardiac Standstill / Flatline
heart’s electrical activities restoring the patient’s
(intrinsic) normal rhythm.

CPR before and after is better (2005 AHA Guidelines for

Electrical Therapy
Effective Defibrillation and Safety
“Countershock”
● Precordial Thump
● AED (Automated External Defibrillator)
● Defibrillation
● Cardioversion
● AICD (Automated Implantable Cardioverter
Defibrillator)
Principles of Early Defibrillation
- Most frequent initial rhythm in a sudden cardiac arrest
is Ventricular Fibrillation (VF)
- The most effective treatment for VF is Defibrillation
- The success of defibrillation diminishes according to the
time
-VF converts asystole within few minutes
Defibrillation can be accomplished:
● Precordial Thump
● External Countershock using defibrillator
● AED- Automated External Defibrillator
CPR or ECC)
If a patient with sudden cardiac arrest from VF is without
treatment for 5 minutes or longer, the outcome may
improve if CPR is performed prior to defibrillation.
- Effective chest compressions help deliver blood
to the coronary arteries and brain.
- It is also important to perform CPR after
defibrillation for the patient may experience a
period of asystole or pulseless electrical activity
which the CPR may help by converting to a more
perfusing rhythm.
However basic CPR can not convert VF to a normal rhythm.
The only way to convert VF and restore normal rhythm is
through defibrillation.
The need for SPEED
If the defibrillation is done with VF patient within 5
minutes of cardiac arrest, the survival rate is 50%.
The survival rate decreases by 7 % to 10% for each minute
that the patient is in VF.
AED
Portable defibrillator with microcomputer that senses and
analyzes patient’s heart rhythm and gives step-by-step
directions on how to proceed if defibrillation is indicated.
- Shocks are automatically delivered with the use
of adhesive pads as needed according to the
machine’s own interpretation.
AED (Automated External Defibrillators)
● Fully Automatic
● Semi Automatic
How should it be done?
- Attach AED only when the patient has no pulse
and respiration.
- Witnessed cardiac arrest- in the hospital with
monitor
- Unwitnessed cardiac arrest – outside the hospital
and no monitor
Witnessed Cardiac Arrest
Initiate CPR immediately and use an AED as soon as
possible.
Unwitnessed Cardiac Arrest
Perform 5 cycles (2 minutes) of CPR before checking the
ECG and attempting to defibrillate.
● Open the pockets containing the two electrode
pads.
● Expose the client’s chest.
● Remove the plastic backing from the electrode
pads.
● Press the ON button.
● Listen to the computerized voice analyzing the
rhythm for 5 to 15 seconds.
● If shock is not needed, the AED will advise to
continue CPR.
● If shock is needed, the AED will announce “STAND
CLEAR” message and emit a beep that changes to
a steady tone as it charges.
● When the AED is fully charged, and ready to
deliver a shock, it will prompt you to press the
shock button.
● Make sure no one is touching the patient or bed
and call out “I’M CLEAR”, YOU’RE CLEAR,
EVERYBODY’S CLEAR, then press the shock button.
● Resume CPR 5 cycles (about 2 minutes).
Purpose of Adhesive Electrode Pads
● To transmit the patient's rhythm.
● To deliver the shock.
Situations requiring a change in actions when using AEDs:
1. Child <1 year old (do not use the AED)
2. Lying in water, move the victim first and dry the
chest wall.
3. With AICD, (implanted pacemaker or defibrillator)
place the electrode pad away from the devices.
4. With a transdermal medication patch, remove the
patch and clean the chest wall.
Treat the client, not the AED machine
- Example: If the AED reads “flatline”, it may only
mean that one of the cable electrodes is
disconnected or it may read normal and the
client is actually on VT.
- Remember that AED only analyzes “rhythm”, it
does not check the pulse.
- CPR is vital and that AED’s purpose is to treat
death-forming dysrhythmias.
Unmonitored / unwitnessed using conventional
defibrillator
- Assess level of responsiveness.
- No response-call 911 and get the AED
- Using manual defibrillator, do “quick look” by
simply placing the paddle on the client’s chest to
quickly view the heart’s rhythm.
- With lethal arrhythmias, (pulseless VT) apply the
conductive medium.
- Turn the defibrillator on and set at the initial
200 joules, no conversion increase to 300 joules,
no conversion increase to 360 joules. Once 360
joules is used, stay to that level.
- Charge the paddles by pressing the charge
buttons on the paddle.
- Press firmly against the client’s chest using
25lbs.
Note: no pulse check needed for the first 3 defibrillations.
The current practice:
Monophasic Vs Biphasic Waveform
Monophasic defibrillators
- Delivers a single current of electricity that travels in
one direction between the two paddles on the patient’s
chest
- To be effective, a large amount of electrical current is
required for monophasic defibrillators.
- 3 stacked shocks delivery without pause
a. 200-300 joules
b. 200-300 joules
c. 360 maximum
Biphasic defibrillators
- Pad or paddle placement is the same. However, the
discharged electrical current travels in a positive
direction for a specified duration and then reverses &
flows in a negative direction for the remaining time of
the electrical discharge, thus delivering 2 or double
currents of electricity.
-more successful conversions
Advantages:
- Requires lower threshold of the heart muscle
allowing more successful defibrillation with
smaller amounts if energy.
- It also adjusts for differences of impedance or
resistance reducing the number of shocks needed.
- RECTILINEAR BIPHASIC WAVEFORM DEFIBRILLATOR
150-200 JOULES
- BIPHASIC TRUNCATED EXPONENTIAL WAVEFORM
(B.E.T.W.) 120 JOULES
Indications:
VENTRICULAR FIBRILLATION
PULSELESS VENTRICULAR TACHYCARDIA
PADDLE PLACEMENT:
- (For standard placement) Antero-Lateral Right-
upper sternum just below the right clavicle
- Left- nipple line and mid-axillary- Anterior /
Posterior
- Manage “Arching” by:
a. Necessary amount of gel applied
b. 25 pounds muscle pressure
- Manage transthoracic resistance :
1. by paddle size (adult 8.5-12 cm diameter ; child
8cm; infant 4.5 cm)
Safety is the first consideration
- Do not use alcohol to clean the paddles.
- Avoid placing the paddles near the monitoring
electrodes.
- Do not tilt the paddles during use to avoid
arching.
- Stand clear from the patient and bed when
discharging the device.
- Do not position the pads over the pacemaker.
Post Defibrillation
● Monitor neurological status
● Cardiovascular status
● Respiratory status
● Blood values
Neurological status
● Level of consciousness
● Pupillary reactions
● Motor / Sensory
● Vital signs that could indicate brain damage /
IIP
Respiratory
● Breathing pattern / status
● Intubated
● Breath sounds
Cardiovascular
● Pulses
● Heart sounds
● Dysrhythmias
● Medication drips
Synchronized cardioversion
● Cardioversion- “synchronized countershock” is the
delivery of timed but direct electrical shock(s) to
the heart as an emergency or elective treatment
performed by an MD or certified RN
● The electrical charge is delivered to the
myocardium at the peak of R wave causing
immediate depolarization allowing SA node to
gain control of the conduction system.
Elective or emergency electrical therapy procedure is used
to treat VT with pulse that is transient or not sustained
and “tachydysrhythmias” if refractory or not responding to
usual mode of treatments like medications or valsalva.
“SYNCHRONIZED”
When electrical current is discharged, it only triggers the
client’s QRS complex to avoid accidental electrical
discharge at the repolarization phase (T wave) due to the
danger of converting to death forming dysrhythmias.
indications:
● Tachydysrhythmias
● Symptomatic
● Refractory to medications
● Conscious or ventricular tachycardia with pulse
What are the 4 usual ways of treating tachydysrhythmias?
● Valsalva
● Medications
● Cardioversion
● Carotid massage
Preparation:
● Explain the procedure.
● Obtain 12L EKG as baseline.
● Connect client to pulse oximeter and BP cuff.
● Connect to the monitoring leads.
● Turn on the defibrillator and set for the
synchronus mode.
● Sedation as ordered.
● Remove dentures / jewelries.
● Empty bladder.
● Check the Digoxin level.
● Prepare by exposing the client’s chest.
● Obtain 12L EKG and write “pre conversion”.
● Have emergency and intubation set ready.

AICD (Automated Implantable Cardioverter Defibrillator)
Priorities:
● Activation status
● Heart rate cutoff
● Number of shock(s) allowed to deliver
Description:
● Pulse generator + Leads
● Weight – ½ lbs.
● Size: a deck of cards
● Implantation: thoracotomy, sternotomy,
transvenous
● CAB via sternotomy
● Pulse generator
● Sensor – monitor client’s EKG continuously:
● will deliver countershock within 15-20 seconds
● can also cardiovert Vtach with pulse
● Nothing will work, not until medications are
used.
● Combination of electrical therapy SHOCK and
Medications
CARDIOPULMONARY RESUSCITATION
Definition
First aid procedure intended to revive a heart and lung
arrest within 3-4 minutes, from the time the heartbeat
and breathing stops to prevent death or irreversible brain
damage.
Purposes
1. To restore patient’s breathing.
2.To assist patient’s blood circulation by keeping the
brain, heart and other vital organs supplied with blood
and oxygen.
3.To maintain life until a victim recovers or advanced life
support is available.
Highlights of the adult CPR 2010
1. Five Links of ADULT CHAIN OF SURVIVAL
2. “Look, listen, and feel for breathing” has been
removed from the algorithm
3. Continued emphasis has been placed on
high-quality CPR
4. C-A-B rather than A-B-C
5. Rate is at least 100/min and depth of at least 2
inches
5 links of the Adult Chain of Survival
- Immediate Recognition of Cardiac Arrest and Early
Access- The chain of survival begins with immediate
recognition of cardiac arrest and rapid activation of EMS
or an Emergency Action Plan.
-Early CPR- Early CPR with emphasis on compression.
● Rapid Defibrillation- Survival rates: highest if
CPR is started immediately & defibrillation is
done w/in 3-5 mins.
● Early Advance Life Support (ALS) - involves
medical procedures and medications used by
paramedics, RNs and MDs.
● Integrated Post-Cardiac Arrest Care- A bundled
treatment strategy after cardiac arrest that
allows the patient’s status to return to normal or
near-normal.
BENEFITS OF CPR
- Compression of the chest cavity can create blood flow
- Combined rescue breaths and chest compressions are
capable of providing some oxygen
- Immediate CPR could double or triple the chances of
survival.
CABs of CPR
A. CIRCULATION
● Victims must be face-up and lying flat on a firm
surface.
To maximize internal blood flow:
● Chest compressions: performed hard and
fast.
● Full chest recoil at the top of each
compression.
● Minimize any interruptions to
compressions.
B. AIRWAY
- head tilt-chin lift maneuver to open the airway
of a victim without evidence of head or neck
trauma.
- one hand on client’s forehead, tilt head with
palm using firm backward pressure
 - fingers of other hand under lower jaw; tilt jaw Mouth-to-Stoma Ventilation
to bring teeth almost to occlusion. Mouth-to-stoma rescue breaths
- reasonable alternative is to create a tight
- Tilting the head and lifting the chin will pull seal over the stoma with a round pediatric
the tongue away from the back of the throat and face mask
open the airway. - no published evidence on the safety,
- Don’t press too hard on the soft area under the effectiveness, or feasibility of mouth-to-stoma
chin. Doing so can block the airway. ventilation.
Jaw- thrust Maneuver
- use in suspected spinal cord injury. STEPS OF CPR
-Open the airway without head extension. 1. Approach Safely
-Stay at client’s head part, elbows on the ● “The scene is safe. Stand Clear!...”
ground/bed, grasp both angles of the lower jaw, 2. Check for Responsiveness and Normal Breathing
lift both hands displacing the mandibles forward ● 3-5 seconds
and tilting head ● Gently shake the shoulders and ask loudly, “HEY!
HEY! ARE YOU OK?” (TWICE) while SCANNING THE
C. BREATHING CHEST for NORMAL BREATHING
- Rescue breath uses your own exhaled air to ● “Patient is unresponsive and breathless…”
force oxygen into the lungs 3. Shout for Help
- Give each breath in one second duration. ● “HELP! CALL 911! ACTIVATE EMS and GET THE A.E.D.”
- Allow the victim to exhale completely between In-hospital Scenario:
breaths. ● “HELP, Activate the code and get an AED!”
- It is recommended to use a barrier device ● IF YOU OR SOMEONE ELSE HAS CALLED THE
- Deliver each rescue breath over a period of 1 EMERGENCY RESPONSE NUMBER, KNEEL AT THE
second. VICTIM’S SIDE NEAR THE HEAD, AND START CPR.
-Give a sufficient tidal volume (by 4. Check Carotid Pulse
mouth-to-mouth/mask or bag mask with or Pulse Check: 5 - 10 secs
without supplementary oxygen) to produce visible 5. Give 30 compressions
chest rise. ● Place the heel of
-Avoid rapid or forceful breaths. one hand @ the
center of the chest
Ventilation With Bag and Mask ● Place other hand on
- made of transparent material with 1-2 L top
capacity ● Interlock/interlace
- When using a bag-mask device, deliver fingers
each breath over a period of 1 second and ● Compress the chest
provide sufficient tidal volume to cause ● a. Rate of
visible chest rise. at least 100/min
● b. Depth of at least 2 inches
Mouth-to-Barrier Device Breathing 6. Open the Airway
- Barrier devices may not reduce the risk of ● Victim must be face up,
infection transmission, and some may on a firm, flat surface.
increase resistance to air flow. ● If victim is lying face
-2 types: face shields and face masks. down: roll him or her over.
● Minimize turning or
twisting of the head and
neck.
Mouth-to-Nose Ventilation ● Blockage: common cause
- mouth cannot be opened, victim is in
tongue.
water, or mouth-to-mouth seal is difficult
● Untrained Responder: HTCL
to achieve ● Trained Responder: HTCL or
JTM for suspected SCI
7. Give 2 Rescue Breaths after 30 Compressions
GIVE 2 SLOW RESCUE BREATHS via:
1. mouth to barrier
2. bag mask technique
*DELIVER BREATHS SLOWLY*
STEPS for MOUTH TO BARRIER DEVICE RESUSCITATION:
● USE: E-C Clamp technique
● Hyperextend patient’s head use:HTCL
● Take a normal breath
● Place lips over one-way valve of the device
● Blow until the chest rises; take about 1 second
● Allow chest to fall
● Repeat (1 second per breath; 1 second interval)
3. Keeping victim’s hand pressed
against the cheek, pull on far leg
to roll victim towards you. Adjust
the upper leg so both the hip and
the knee are bent at right angles
CPR: Recovery Position:
Injured Patient
1. Kneel beside the victim. Place the
victim’s closest arm above the head
and the furthest arm across the chest.
Bend the victim’s nearest leg at the
knee.

8. Continue CPR for a total of 5 cycles at 30:2, 2. Place your hand under the hollow of
Compression to Ventilation Ratio. the victim’s neck to help stabilize. Roll
During Chest Compression: patient towards you so that the head
● Do not bend elbows rests on the extended arm.
● Hands facing northward
3. Bend legs at the knees to stabilize
● Arms of rescuer: perpendicular to client’s
the victim.
sternum- “PUSH DOWN”
● HEEL OVER THE STERNUM
CPR
● When possible, change CPR operator every 2
*NOTE: Attach and use AED as soon as it is available
minutes
● If AED arrives:
● 5 cycles = within 2 minutes
○ Stop CPR,
● 1 cycle= in less than 18 seconds
○ Place the patches
○ Follow voice prompt of the AED.
9. Reassess for breathing and pulse
***If SHOCK is advised, stay clear***
A. If breathless and pulseless:
● After defibrillating, continue CPR for 5 cycles
Repeat another 5 cycles for 2 minutes at 30:2 ratio
again.
B. If with pulse but no breathing:
Provide ventilation at 1 every 5-6 seconds for 2 minutes
C. If with spontaneous pulse and breathing:
Place on recovery position

CPR: Recovery Position:

Uninjured Patient
1. Kneel beside the
victim; make sure both legs
are straight. Place the arm
nearest to you out at a right
angle to the body, elbow bent
palm up

2. Bring far arm across chest;

hold back of hand against
victim’s cheek nearest you.
With your other hand, grasp
far leg just above knee and
pull up
WHEN TO STOP CPR?
● Spontaneous breathing and pulse is present
● Team (EMS) arrives
● Over-exhaustion of the rescuer
● Physician declares the patient dead
● Scene is unsafe

COMPLICATIONS OF CPR
● Fractured Ribs
● Lacerated Liver
● Atelectasis (punctured lungs)
● Gastric Distention

Infant CPR
INFANT CPR (0 – 12 months) Care of a Patient on a Ventilator
1. Tap the infant’s foot and shout “Baby, baby are you OK?”
Respiratory volume and capacity (normal values)
while scanning chest for movement. 1. Tidal volume (TV): amount of air moved in and
2. If the infant is unconscious, call for help. out of lungs with normal quiet respiration (500
3. Place the infant on a table mL)
or on a firm, flat surface. 2. Inspiratory reserve volume (IRV): amount of air
4. Check for the brachial that can be forcibly inhaled over the tidal
pulse. volume (2100 -3100 mL)
5. Place 3 fingers directly at 3. Expiratory reserve volume (ERV): air that can be
the center of the chest forced out over tidal volume (1000mL)
(nipple line). 4. Residual volume: volume of air remaining in
6. Raise your index finger so lungs after forced expiration (1100 mL)
that the middle and index 5. Vital capacity: TV + IRV +ERB (4500 ml)
fingers are a width below the 6. Dead space volume: amount of air remaining in
nipple line.
passageways (150mL)
7. Compress for approx. 1 ½
inches or 4 cm.
8. If the patient is not breathing prepare for artificial
respirations.
9. Seal infant’s nose and mouth using BVM.
10. Deliver 2 gentle puffs of air at 1 second interval.
11. Reassess the infant after 5 cycles.

Mechanical Ventilators
● Artificially controls or supports breathing efforts
of a patient who is suffering from respiratory
failure.
● Helps prevent alveolar collapse by supplying
adjunctive therapies
● The goal is to maintain alveolar ventilation,
correct hypoxemia and maximize O2 transport
 when client cannot sustain spontaneous and 3. Administer sedatives prn.( To keep patient calm)
effective respirations. 4. Auscultate breath sounds
5. Monitor ventilator settings
Disorders which may require MV 6. Change tubings prn.
● Gas Exchange disorders 7. Perform CPT as needed
- Severe RTI 8. Monitor ABG, O2 sat. , V/S
- Pulmonary emboli 9. Asses position change
- ARDS 10. Provide alternate communication measures
- Pulmonary trauma 11. Suctioning prn.
- Pulmonary arrest 12. Respond to alarms
● Extra-pulmonary disorders
- Guillain-Barre syndrome Puritan-Bennett 7200 Ventilatory System
- Flail chest - Combines improved microprocessor technology with an
- Other musculoskeletal disorders advanced pneumatic system to achieve reliable and
- Post –surgical cases accurate gas delivery and patient monitoring.
Complications from Mechanical Ventilation - It can mix air and oxygen, warm and humidify the mixed
● CardioVascular – HPN, Tachyarrhythmias gas; It provides breath of predetermined tidal volume,
● Pulmonary- Baro trauma, atelectasis peak inspiratory flow, wave form and oxygen
● Gastrointestinal- stress ulcers composition(mandatory breath)
● Neurologic- increased ICP - It can allow a patient to inspire gas having a
● Acid-base disturbance predetermined oxygen consumption from a demand
● Psychological - anxiety system.
● Equipment failure
Features of the Keyboard Panel
Types of Ventilators ● The Patient Data (green background)
● Negative pressure ventilators - provides information on breath types, pressures,
● Volume cycled ventilator volumes, rates
● Pressure cycled ventilator ● The Ventilator Settings (Blue background)
● High frequency ventilators - used by the operator to select ventilatory
Adjuncts to mechanical ventilation settings by a 2 or 3-step entry sequence
● PEEP – for pts. With acute restrictive lung disease ● The Ventilator Status (Grey background)
or intra throracic bleeding. - reports the operating condition and the alarm
● CPAP – for pts. With decreased FRC, fluid filled status.
alveoli, atelectasis, post-operatively Terms
● Adverse effect: Baro Trauma – caused by too high CMV ( Controlled Mandatory Ventilation)
pressure settings - For respirator fully dependent persons e.g.
comatose needing a back-up rate of 16-20 RR
Nursing care Goals for patients on Mechanical Ventilation SIMV (Synchronized Intermittent Mandatory Ventilation)
● Clear, patent airway - For respirator partially dependent persons e.g.
● Maintenance of respiratory volume, pressure and with few spontaneous respirations needing a
oxygen exchange back-up rate of < 16 RR
● Adequate nutrition CPAP ( Continuous Positive Airway Pressure)
● Maintenance of normal electrolytes and serum - For respirator –hooked patients with self
osmolality breathing capacity already requiring a zero
● Maintenance of communication back-up rate
● Prevention of complications from immobility and PEEP (Positive End Expiratory Pressure)
disturbed mucus membranes. - a maintenance of at least 5 cm H2O to prevent
● Management of anxiety reverse atelectasis; Side effects include < cardiac
output due to increased positive intra-thoracic
Nursing Care
pressure.
1. Note ETT position. Monitor cuff pressure
2. Restrain only if needed
Normal Standards in Control
● Tidal volume – Kg.BW X 10
● Sigh Volume – tidal volume X 2
● Peak Flow (O2 content in L/min) – initially set at
40-60 (adults) and lower for infants and children
the higher the PF the faster and shorter the
inspiration; the lower the PF, the slower and
longer the inspiration.
● Pressure Limit – plus 10-20 PH20 of reading on
manometer( regulates pressure to prevent
baro-trauma)
Problems with pressure
- High pressure – caused by any obstruction in
tubings or patient.
- Low Pressure – caused by leaks of oxygen in the
system.
● PEEP Control - 5-10 or less than 5
● Humidifier temp. control to prevent overheating
of the humidifier
● Fio2 – usually starts from 40-50 then regulated
Set-up
Procedure for MV Series 7200
● Attach tubes without proximal line.
● Fill humidifier with water to desired level
● Switch power on at the side of the machine
● Set Tidal Volume at 0.5 and press enter
● Set the RR back-up rate and press enter.
To change RR – press clear, change number then
press enter
● Manipulate the PEEP knob – turn clockwise to
increase and counterclockwise to decrease.
● Select Mode and press enter (CMV, SIMV, CPAP)
For Suctioning with MV
● select the suction button and press enter. (There
is an automatic 100% O2 flow)
● Proceed with normal suctioning procedure
Using the Humidifier
● Sterile, distilled, mineral water, boiled water are
acceptable for the machine
● Do not use NSS or Tap water
● Humidifier water is ideally changed every 8 hours
● To Change fluid, bypass and change within 5
minutes.
Weaning Patients from a Ventilator
● Assess patient’s readiness for weaning
● Select the appropriate method (Start with CMV,
shift to SIMV, then shift to CPAP) while
monitoring blood gasses and allowing the vital
signs to normalize; evaluate progress.
● To adjust FiO2 – press the % O2 button, choose
the number (60-100) then press enter
● During weaning, if CPAP is not tolerated shift
back to SIMV or CMV
● Extubation
● Continue monitoring, assessing and evaluating
progress.
Weaning Parameters:
● Hemodynamic stability (V/S, CVP, Cap. WP)
● PaO2 is over 70-80 mmHg
● PaCO2 = normal (35-45 mmHg)
● Acceptable general respiratory status (12-25)
● Correction of underlying problem
● Patient is calm and responsive
Trouble shooting for MV alarms
● High pressure Limit ( should not be more than 60)
1. Check the patient
2. Check the tubes for obstruction
3. Check the settings of the ventilator for high
pressure limit.
4. Decrease PEEP if indicated (5-15 limit)
● Low inspiratory pressure
1. Check the patient
2. Check the tubes for leaks, holes or loose
connections.
3. If using an oxygen tank, levels of 40PSI and
below should have a change of tank to maintain
FiO2
● I:E Ratio (normally 1:2)
1. Check the patient
2. Patients with ARDS, PTB, Pneumothorax and COPD
require low pressure limit
● Humidifier Temperature
1. Set the temperature below body temperature
Manipulating for Automatic Ambu-Bagging
● Choose CPAP button or reduce RR to 1 or Zero
● Press enter
● Press Manual ventilation every after 5 seconds
Advanced Cardiac Life Support
Defibrillation
Defibrillation can be accomplished by:
- Precordial Thump- manual type
- External Countershock using defibrillator
- AED- Automated External Defibrillator
- AICD- Automated Implantable Cardioverter Defibrillator
CPR before and after is better
If a patient with sudden cardiac arrest from VF is without
treatment for 5 minutes or longer, the outcome may
improve if CPR is performed prior to defibrillation.
❖ Effective chest compressions help deliver blood to the
coronary arteries and brain.
❖ After defibrillation the patient may experience a
period of asystole or pulseless electrical activity which
the CPR may help by converting to a more perfusing
rhythm.
❖ But CPR alone cannot convert VF to a normal rhythm.
The only way to convert VF and restore normal rhythm is
through defibrillation.
Defibrillation
MONOPHASIC
- Delivers a single current of electricity that travels in
one direction between the two paddles on the patient’s
chest
- To be effective, a large amount of electrical current is
required; 200-360 joules
BIPHASIC
- Discharged electrical current travels in a positive
direction for a specified duration and then reverses &
flows in a negative direction for the remaining time,
- Delivers 2 or double currents of electricity.
- 120-200 joules
Lead placement and pressure
- Anterior-apex placement
- Anterior- posterior placement
- Manage “Arching” by:
a. Necessary amount of gel applied
b. 25 pounds muscle pressure
- Manage transthoracic resistance :
A.by paddle size (adult8.5-12 cm diameter; child 8cm;
infant 4.5 cm)
Procedure
1. Verify patient is in cardiac arrest, with no pulse or
respiration. Have someone provide CPR, if possible, while
the defibrillator is obtained and placed next to the
patient.
2. Turn on defibrillator; verify all cables are connected.
3. Turn “lead select” to “paddles” or “defibrillator.”
4. Select initial energy level (AHA 2020 guidelines is 200J
for biphasic or use manufacturer’s recommendation).
5. Paddles/ pads: Use conducting gel and place paddles
properly on chest
6. Verify rhythm as VF or pulseless VT.
7. Say, “Charging defibrillator, stand clear!”
8. Charge defibrillator.
9. Say, “I’m going to shock on three. One, two, three while
performing a visual sweep to assure all rescue personnel
are clear of patient, bed, and equipment.
10. Discharge defibrillator
11. Re-assess rhythm,and refer to appropriate treatment
algorithm for resulting rhythm. You may switch roles at
this time.
Safety is the first consideration
- Do not use alcohol to clean the paddles.
- Paddles are placed together when moving from
machine to patient.
- Avoid placing the paddles near the monitoring
electrodes.
- Do not tilt the paddles during use to avoid arching.
- Stand clear from the patient and bed when
discharging the device.
- Do not position the pads over the pacemaker.
Synchronized Cardioversion
- Cardioversion- The electrical charge is delivered to the
myocardium at the peak of R wave causing immediate
depolarization allowing SA node to gain control of the
conduction system.
- Synchronization avoids accidental electrical discharge at
the repolarization phase (T wave) and the danger of
converting to death forming dysrhythmias.
- Sync mode delivers energy just after the R wave to
avoid stimulation during the absolute refractory period.
Indications:
- Tachydysrhythmias
- Symptomatic
- Refractory to medications
- Conscious or ventricular tachycardia with pulse
CARDIOVERSION (Synchronized)
Application:
- Press the sync button in the defibrillator machine
- Select energy levels
Atrial – 50Joules initial
Ventricular – 100Joules initial
- For conscious patients explain the procedure
- Use a medication for sedation. Consider
2.5 – 5.0 mg of Midazolam (Dormicum), or
5 mg Diazepam (Valium).
- Follow the verbal and visual steps of defibrillation
- Reactivation of sync mode is required because
Defibrillators default to unsynchronized mode

ACLS Algorithms
Checking of the H and T’s
- Hypovolemia
- Hypoxia
- H+ ion acidosis
- Hyper/hypokalemia
-Hypothermia
-Tension Pneumothorax
- Tamponade
Hypovolemia
- Cause: bleeding, anaphylaxis or fluid shifting
- Rhythm: PEA
- Treatment:
- Fluid resuscitation 3:1 (300mL of fluid per 100mL loss)
- Blood transfusion
- Fluid loss control

Call Assessment

Labs: CBC Assess for obvious signs of

bleeding
Vital signs / hemodynamics

Urine Specific Gravity if Assess output

applicable

Hypoxia
- Decreased oxygen delivery to cells (heart, brain and
lungs)
- Causes: Asthma, COPD, CHF fluid volume overload,
Respiratory Depression
- Treatment: Oxygen, Ventilation and Good chest
compression
- Rhythm:
- PEA
- Asystole
- Ventricular fibrillation
- Ventricular Tachycardia

Call Assessment

Labs: STAT ABGs Oxygen Saturation

Check for moisture at mask
Hydrogen Ions
- Abnormal body pH of < 7.35 resulting in acidosis
Call Assessment
- Cause: Shock, DKA, Renal Failure and overdose
- Rhythm: Asystole, PEA STAT Serum Blood Glucose Retrieve Serum blood
- Treatment: Proper ventilation, good CPR, glucose levels
NaHCO3
STAT HBA1C results CBG assessment
Call Assessment

Labs: STAT ABGs Assess ECG rhythms Tablets or TOXINS

- Overdosage, medication reaction or substance abuse
Causes: medications and street drugs
Hyperkalemia / Hypokalemia
Rhythm: PEA, Asystole, PVT, VF
Hyperkalemia: > 5.0 mEq/L
Treatment: antidote administration, IVF, vasopressors,
Cause:
cardiac bypass
- Hyperkalemia: renal failure, missed dialysis
Rhythm: Call Assessment
- Hyperkalemia: PEA / Asystole
Treatment: STAT serum levels of drug
- Hyperkalemia: NaHCO3, glucose and insulin or medications

Hypokalemia: < 3.5 mEq/L Cardiac Tamponade

Cause: - Build up of air or fluid in the pericardium Causes:
● Hypokalemia: diarrhea, malnutrition, N/V pleural effusion, trauma, vessel rupture,
Rhythm: liver disease
● Hypokalemia: Ventricular Fibrillation, PVT, Rhythm: PEA
Asystole Treatment: Pericardiocentesis and thoracotomy
Treatment:
Call Assessment
● Hypokalemia: potassium supplement
STAT Chest Xray Assess ECG rhythm Auscultate heart
Call Assessment sounds

STAT serum potassium Check serum potassium results Palpate pulse during compressions
levels Assess ECG rhythms Check BP

Hypothermia Tension Pneumothorax

- Body core of less than 35 degrees Celsius - build up of air in the pleural cavity
Causes: traumatic injury, rapid injury Causes: Traumatic injury, barotrauma, central line
resuscitation, drowning homelessness placement, CPR
Rhythm: PEA, asystole Rhythm: PEA
Treatment: warm IVF, lavage with warm fluid, Cardiac Treatment: 100% oxygen, needle thoracotomy
bypass Call Assessment
Call Assessment
STAT: PT, PTT. Vitamin K levels, Auscultate for lung
Platelet sounds during
Take core temperature
Bleeding time, Clotting time ventilations

Hyperglycemia / Hypoglycemia
Thrombosis
- Blood glucose levels of >120 or <60 mg/dL
- blockage of one or more coronary arteries causing
Causes: poor diet and poor medication regimen for
sustained ischemia and more areas of cardiac muscle
hyperglycemia and too much insulin and skipping meals
Causes: history of cardiac risk factors or known cardiac
for hypoglycemia
disease
Treatment: Normal Saline and Insulin for hyperglycemia
Rhythm: Ventricular Fibrillation and Pulseless Ventricular
and IV D50 for hypoglycemia
Tachycardia
 Treatment: Thrombolytics and PTCA 7. Draw blood for ABGs
8. Call ICU nurse and endorse
Call Assessment

STAT: PT, PTT. Vitamin K levels, Assess pulse at the

Platelet carotid area during
Bleeding time, Clotting time compressions

Thromboembolism
- pulmonary artery is blocked by thrombosis
Causes: DVT, history of A Fibrillation, long bone fracture
Rhythm: PEA, asystole
Treatment: Dopamine, heparin, thrombolytics

Call Assessment

STAT: PT, PTT. Vitamin K levels, Assess pulse at the carotid

Platelet area during compressions
Bleeding time, Clotting time

Auscultate for lung sounds

Targeted Temperature Management

- Follows command?
- Induce therapeutic hypothermia
- 32°C to 34°C core body temperature
- 12 or 24 hours
- Normal saline solution with a temperature of4°C
-Succeeding days, if patient remains comatose, the
following test can be done to check for brain activity:
- EEG (Electroencephalogram)
- MRI (Magnetic Resonance Imaging) - NSE
(Neuron-specific Enolase)

Post Cardiac Arrest Care

1. Oxygen therapy
2. Insert NGT
3. Replace 3 lead ECG to 12 lead ECG
4. Insert Central Line
5. Request for X-rays
6. Insert urinary catheters