Section 10.3: High-Acuity, Emergency Nursing, and Crisis Intervention

Crisis Intervention and Suicide Prevention

A crisis is an acute, time-limited event (usually lasting 4 to 6 weeks) where a client experiences an overwhelming emotional reaction to a stressful situational, developmental, or societal event. The individual's usual coping mechanisms fail, leading to severe disorganization.

Goals of Crisis Intervention: The primary goal is strictly focused on resolving the immediate problem and returning the client to their pre-crisis level of functioning (or higher). It is not designed for deep psychological exploration or personality restructuring. The nurse takes a highly directive and active role in problem-solving.

Suicide Prevention Protocol: Clients in acute crisis may present with suicidal ideation. The nurse must conduct a direct lethality assessment:

1. Ideation: Are you thinking about killing yourself?
2. Plan: Do you have a plan to do it?
3. Method: What is your plan? Do you have access to the method (e.g., guns, pills)?
4. Intent: Do you intend to carry out this plan today? If a client is deemed at high risk, place them on strict one-to-one (1:1) continuous observation. Ensure their hands are always visible, search their belongings for contraband, and utilize plastic utensils during meals. Do not leave the client alone under any circumstances.

Domestic Violence and Abuse

Nurses frequently encounter victims of domestic violence in emergency settings. The primary role of the nurse is to provide a safe, non-judgmental environment, treat physical injuries, and empower the client.

Nursing Considerations:

• Interviewing: Always interview the suspected victim in absolute privacy, away from the partner or accompanying individuals. The abuser often attempts to answer questions for the victim.
• Documentation: meticulously document injuries using body maps, exact measurements, and the client's own words enclosed in quotation marks.
• Legal Mandates: While the nurse must report suspected child abuse and elder abuse to relevant authorities under Philippine law, adult victims of intimate partner violence generally hold the right to choose whether to report the abuse, though the nurse must provide resources and a safety plan.

Emergency Room Triage

Triage in the emergency department (ED) is the process of rapidly classifying patients based on the severity of their condition to allocate resources efficiently. The standard framework often utilizes a color-coded or tier-based system:

1. Resuscitation (Level 1 / Red): Immediate, life-threatening condition requiring instantaneous intervention (e.g., cardiac arrest, massive trauma, severe respiratory distress).
2. Emergent (Level 2 / Orange): High risk for deterioration; intervention required within minutes (e.g., chest pain suspected as myocardial ischemia, acute stroke symptoms, severe hemorrhage).
3. Urgent (Level 3 / Yellow): Stable at the moment, but requires multiple resources and intervention within an hour (e.g., complex lacerations, acute abdominal pain, displaced fractures).
4. Non-urgent/Minor (Level 4/5 / Green/Blue): Routine conditions requiring minimal resources (e.g., mild upper respiratory infection, medication refills, simple rash).

Care of the Client in Shock

Shock is a life-threatening clinical syndrome characterized by inadequate systemic tissue perfusion, leading to cellular hypoxia, anaerobic metabolism, and eventual multiple organ dysfunction syndrome (MODS).

Types of Shock:

• Hypovolemic: Loss of intravascular volume (hemorrhage, severe dehydration, extensive burns).
• Cardiogenic: Pump failure of the heart (massive myocardial infarction, severe heart failure).
• Distributive: Massive vasodilation causing relative hypovolemia (Anaphylactic, Neurogenic, and Septic shock).
• Obstructive: Physical obstruction to blood flow (cardiac tamponade, massive pulmonary embolism).

General Nursing Management for Shock:

• Airway and Breathing: Ensure a patent airway and administer high-flow supplemental oxygen. Anticipate intubation for severe respiratory compromise.
• Circulation: Establish two large-bore IV lines (18 gauge or larger).
• Fluid Resuscitation: Rapidly administer isotonic crystalloids (Normal Saline or Lactated Ringer's) or blood products, particularly for hypovolemic and septic shock. Note: Fluid administration is cautious and limited in cardiogenic shock to prevent fluid overload.
• Pharmacology: Administer prescribed vasoactive medications (e.g., norepinephrine, dopamine, epinephrine) via a central line to restore vascular tone and cardiac output once intravascular volume has been adequately replaced.
• Monitoring: Continuously monitor vital signs, central venous pressure (CVP), and insert an indwelling catheter to precisely measure hourly urine output (a key indicator of organ perfusion, with a minimum acceptable output of 30 mL/hr).

Basics of Mechanical Ventilation

Mechanical ventilation is used to support oxygenation and ventilation when a client is in acute respiratory failure.

Core Nursing Responsibilities:

• Assess the Client First, Not the Monitor: If an alarm sounds, immediately assess the client's respiratory status, oxygen saturation, and bilateral breath sounds before troubleshooting the machine.
• High-Pressure Alarms: Triggered by increased airway resistance. Common causes include secretions in the airway (requires suctioning), the client biting the endotracheal tube, coughing, or a pneumothorax.
• Low-Pressure Alarms: Triggered by a loss of resistance or a leak. Common causes include ventilator tubing disconnection or extubation.
• Preventing VAP (Ventilator-Associated Pneumonia): Maintain the head of the bed elevated at 30 to 45 degrees, perform strict oral care with chlorhexidine routinely, practice stringent hand hygiene, and assess daily for readiness to extubate.