Emergency Room Cases

1. Acute Appendicitis

Definition: A condition characterized by inflammation of the appendix. It is a medical

emergency. All cases require removal of the inflamed appendix, either by laparotomy or
laparoscopy. Untreated, mortality is high, mainly because of peritonitis and shock.

Causes: On the basis of experimental evidence, acute appendicitis seems to be the end
result of a primary obstruction of the appendix lumen. Once this obstruction occurs the
appendix subsequently becomes filled with mucus and swells, increasing pressures within
the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small
vessels, and stasis of lymphatic flow. As the former progresses, the appendix becomes
ischemic and then necrotic. Among the causative agents, such as foreign bodies, trauma,
intestinal worms, and lymphadenitis, the occurrence of an obstructing fecalith has
attracted attention.

Symptoms: Pain in the right iliac fossa, diarrhea. The abdominal wall becomes very
sensitive to gentle pressure (palpation). Also, there is rebound tenderness. Coughing
causes point tenderness in this area (McBurney's point) and this is the least painful way to
localize the inflamed appendix.
Rovsing's sign Deep palpation of the left iliac fossa may cause pain in the right iliac
fossa. This is the Rovsing's sign, also known as the Rovsing's symptom. It is used in the
diagnosis of acute appendicitis. Pressure over the descending colon causes pain in the
right lower quadrant of the abdomen.
Psoas sign This is right lower-quadrant pain that is reproduced with the patient lying on
his left side and then extending the hip. Because extension elicits pain, the patient will lie
with the right hip flexed for pain relief.
Obturator sign If an inflamed appendix is in contact with the obturator internus, spasm of
the muscle can be demonstrated by flexing and lateral rotation of the hip. This maneuver
will cause pain in the hypogastrium.

Nursing Responsibility:

1.) Nursing goals include relieving pain, preventing fluid volume deficit, reducing
anxiety, eliminating infection due to the potential or actual disruption of the
gastrointestinal tract, maintaining skin integrity, and attaining optimum nutrition.
2.) Prepare patient for surgery, start intravenous line, administer antibiotic, and insert
nasogastric tube (if evidence of paralytic ileus). Do not administer an enema or
laxative (could cause perforation).
3.) Postoperatively, place patient in semi-Fowler’s position,
4.) Give narcotic analgesic as ordered, administer oral fluids when tolerated, give food
as desired on day of surgery (if tolerated). If dehydrated before surgery, administer
intravenous fluids.
5.) If a drain is left in place at the area of the incision, monitor carefully for signs of
intestinal obstruction, secondary hemorrhage, or secondary abscesses (eg. fever,
tachycardia, and increased leukocyte count).
2. Placenta Previa

Definition: is an obstetric complication in which the placenta is lying unusually low in your
uterus, next to or covering your cervix.
Causes/risk factors: You had placenta previa in a previous pregnancy.
•You're pregnant with twins or higher-order multiples.
•You've had c-sections before. (The more c-sections you've had, the higher the
risk.)
•You've had some other uterine surgery (such as a D&C or fibroid removal).
•You're a cigarette smoker.
• You use cocaine.Also, the more babies you've had and the older you are, the
higher your risk.
Symptoms:
It can sometimes occur in the later part of the first trimester, but usually during the second
or third. It is a leading cause ofantepartum hemorrhage (vaginal bleeding)
No specific cause of placenta previa has yet been found but it is hypothesized to be
related to abnormal vascularisation of the endometrium caused by scarring
or atrophy from previous trauma, surgery, or infection
Women with placenta previa often present with painless, bright red vaginal bleeding. This
bleeding often starts mildly and may increase as the area of placental separation
increases. Previa should be suspected if there is bleeding after 24 weeks of gestation.
Abdominal examination usually finds the uterus non-tender and relaxed.
Leopold's Maneuvers may find the fetus in an oblique or breech position or lying
transverse as a result of the abnormal position of the placenta. Previa can be confirmed
with an ultrasound.

Nursing Responsibilty:
Ensure the physiologic well-being of the client and fetus
a. Take and record vital signs, assess bleeding, and maintain a perineal pad count.
Weigh perineal pads before and after use to estimate blood loss.

b. Observe for shock, which is characterized by a rapid pulse, pallor, cold moist skin
and a drop in blood pressure

c. Monitor the FHR

d. Enforce strict bed rest to minimize risk to the fetus

e. Observe for additional bleeding episodes.

Provide client and family teaching

a. Explain the condition and management options. To ensure an adequate blood
supply to the mother and fetus, place the woman at bed rest in a side-lying
position. Anticipate the order for a sonogram to localize the placenta. If the
condition of mother or fetus deteriorates, a cesarean birth will be required.

b. Prepare the client for ambulation and discharge ( may be within 48 hours of last
bleeding episode)

c. Discuss the need to have transportation to the hospital available at all times.
 d. Instruct the client to return to the hospital if bleeding recurs and to avoid
intercourse until after the birth.

e. Instruct the client on proper handwashing and toileting to prevent infection.

Address emotional and psychosocial needs

a. Offer emotional support to facilitate the grieving process, if needed

b. After birth of the newborn, provide frequent visits with the newborn so that the
mother can be certain of the infant’s condition

3. Dengue fever
• Is an acute febrile (accompanied by fever) disease.
• Caused by a single-stranded RNA flavivirus
• Carried byAedes mosquitoes, usually prevalent in tropical and sub- tropical reigons.
• Also known as breakbone fever, because of the severe pain induced in the muscles and
joints, although it does not actually break bones.

Causes: Dengue fever is caused by any one of four dengue viruses spread by the Aedes
aegypti mosquito. These mosquitoes thrive in and near human habitations, where they
breed in even the cleanest water.

Signs & Symptoms:

Incubation period
Incubation period ranges from three to 15 (usually five to eight) days
before the signs and symptoms of dengue appear. So it could be a
week after the individual was bitten before the signs and symptoms
start to manifest.
• Starts with chills, headache, pain upon moving the eyes, and low backache.
• Painful aching in the legs and joints occurs during the first hours of illness.
• The temperature rises quickly as high as 104° F (40° C), with relative low heart rate
(bradycardia) and low blood pressure (hypotension).
• The eyes become reddened.
• A flushing or pale pink rash comes over the face and then disappears.
• The glands (lymph nodes) in the neck and groin are often swollen.
• Fever and other signs of dengue last for two to four days, followed by rapid drop in
temperature (defervescence) with profuse sweating. This precedes a period with normal
temperature and a sense of well-being that lasts about a day.
• A second rapid rise in temperature follows. A characteristic rash
appears along with the fever and spreads from the extremities to cover
the entire body except the face.

Nursing Interventions:
Dengue is a self-limited illness but recovery might take a few weeks.
Independent:

• Close monitoring of vital signs in critical period (between days 2 to day7 of fever) is
critical.
 • Icreased oral fluid intake is recommended to prevent dehydration.
• Treatment is purely concerned with relief of the symptoms(symptomatic).

Dependent:
• Because dengue is caused by a virus, there is no specific medicine or antibiotic to
treat it.
• Aspirin and nonsteroidal anti-inflammatory drugs should be avoided as
• these drugs may worsen the bleeding tendency associated with some of these
infections.
• Acetaminophen (Tylenol) and codeine may be given for severe
• headache and for the joint and muscle pain (myalgia). (DHF) Oxygen and
sedatives may be administered.
Collaborative:
• A platelet transfusion is indicated in rare cases if the platelet level
• drops significantly (below 20,000) or if there are significant bleeding.
• The presence of melena or blood in the stool may indicate internal
• gastrointestinal bleeding requiring platelet and/or red blood cell
• transfusion

4. Transient Ischemic Attack

Transient ischemic attack is also known as a mini-stroke, a hemorrhagic stroke, or an

ischemic stroke. Some people call a TIA a mini-stroke, because the symptoms are like
those of a stroke but do not last long. Generally, a TIA happens when platelets in the
blood clump together in your arteries (a blood clot) making blood flow to a part of the brain
be blocked or reduced. After a short time, blood flows again and the symptoms go away.
Symptoms usually last only 10 - 15 minutes and clear up within 24 hours. With a stroke,
the blood flow stays blocked, and the brain has permanent damage. TIAs sometimes
happen before strokes, and they are considered a warning sign of stroke.

Causes: Age: Advancing age is one of the most significant risk factors of stroke.
Sex: Stroke has higher incidence in men due to physical needs and built.
History of TIA/Stroke & HTN in the family: Genetic predisposition of
stroke.
Sedentary lifestyle: Persons with a sedentary life style are at higher risk for stroke than
those with active life styles.
History of HTN: High blood pressure increases the pressure inside arteries, causing
damage. Excessive pressure on the walls of vessels speeds up hardening and narrowing
of the arteries (atherosclerosis).
Precipitating Factors
Cigarette smoking: Smoking injures blood vessel walls and speeds up hardening of the
arteries (atherosclerosis). As a result, the heart works harder, and blood pressure may
increase. Heavy smokers are at greater risk for TIA and stroke. Daily cigarette smoking
can increase the risk of stroke by 2½ times. Diabetes Mellitus: People who have diabetes
are at increased risk for many serious health problems, including hardening of the arteries
atherosclerosis) and heart problems, eye problems that can lead to blindness, circulation
and nerve problems, and kidney disease and kidney failure.
Thromboembolism: A blood clot or other tissue in the blood (such as fat) from a part of the
body other than the brain can travel through blood vessels and become wedged in a
smaller brain artery. This free-roaming clot or tissue is called an embolus (emboli is plural).
Emboli often form in the heart. They also commonly form in the neck arteries or within the
aorta.
Signs and Symptoms:
Blurred vision in both eyes, brief blindness, or double vision
Parietal and temporal lobe strokes may interrupt visual fibers of the optic tract and
route to the occipital cortex and impair visual acuity.
Difficulty speaking
It is caused by cranial nerve dysfunction from a stroke in vertebrobasilar
artery or its branches. It may result from the weakness or paralysis of the muscles of
the lips, tongue, and larynx or form loss of sensation.
Weakness, sometimes on only one side of the body
The deficit is usually caused by a stroke in the anterior or middle cerebral
artery, leading to infarction of motor strip of the frontal cortex.
Vertigo (a whirling or spinning feeling), headache, confusion
They occur due to decreasing oxygen level or total oxygen deprivation.
Loss of consciousness
It occurs due to impaired Oxygen absorption, altering or disturbing brain cell
metabolism and functioning.
Chest pain
Anything that compresses a nerve root (like a disc or multiple discs) due to cardiac
ischemia will hurt.
NURSING RESPONSIBILITIES:
-monitor patient neurological status.
-make sure that patient’s bed has side rails. To prevent patient from falling when
dizziness occurs.
-monitor patient’s hydration as much as possible.
-encourage early ambulation when possible
 -educate patient about smoking, its effects, diet regimen included.

5.)measles
An acute, contagious viral disease, usually occurring in childhood and characterized by
eruption of red spots on the skin, fever, and catarrhal symptoms. Also called rubeola.
Black measles. Any of several other diseases, especially German measles, that cause
similar but milder symptoms.
Causes:
infection caused by a virus, which causes an illness displaying a characteristic skin
rash.
Signs and Symptoms:

Dry Persistent Cough Four day fevers that reach up to 40˚C

Coryza (runny nose) (104˚F)
Conjunctivis (Red Eyes) Red Blotchy Skin Rash
Sore Throat Sensitivity to light
Koplik’s Spots (grayish pecks)

Nursing Responsibilities:

• Emphasize the need for immediate isolation when early catarrhal symptoms
appear.
• Observe closely the patient for complications during and after the acute stage.
• Teach, demonstrate, guide and supervise adequate nursing care indicated.
• Explain the proceedings, in proper disposal of nose and throat discharges.
• Explain concurrent and terminal disinfection
• Nursing Care
• Protect the eyes of the patients from glare of strong light as they are apt to
• be inflamed.
• Keep the patient in an adequately ventilated room but free from drafts and
• chilling to avoid complications of pneumonia.
• Teach, guide and supervise correct technique of giving sponge bath for
• comfort of patient.
• Check for corrections of medication of treatment prescribed by the physician
Emergency Room Procedures

1.) Casting- Provides rigid immobilization of affected body part for support and stability
May be plaster or fiberglass (lighter weight, stronger, water-resistant, porous; diminishes
skin problems, does not soften when wet). Other material include synthetic acrylic,
fiberglass-free, latex-free polymer, or a hybrid of materials
•Application gen. incorporates the joints above and below a fracture to restrict
tendoligamentous movement.

NURSING RESPONSIBILITIES:
• Observation of respiratory status
• Bowel and bladder function
• Areas of pressure over bony prominences
• Reposition pt. every 2-3 hours= promote even cast drying and relieve pressure and
discomfort
• Apply ice over fracture site for first 24 hr
• (avoid getting cast wet by keeping ice in plastic bag and protecting cast with cloth
• Dry cast thoroughly after exposure to water (blot dry w/towel; use hair dryer on low
• Setting )

2.) Splinting
To stabilize the extremity
• To decrease pain
• Actually treat the injury

NURSING RESPONSIBILITY:
• Observation of respiratory status
• Elevate extremity above the level of the heart
• Move joints above and below cast regularly.
• Report signs of possible problems to health care provider: increasing pain, swelling
assoc. w/pain and discoloration of toes/fingers, pain during movement, burning or
tingling under cast, sores/foul odor under cast
• Keep appointment to have fracture and cast checked

3.) Thoracotomy is an operation to open the chest to explore, inspect and operate on a
chest organ (lungs/heart/trachea (windpipe)/oesophagus (food pipe) etc).
NURSING RESPONSIBILTY:
• Assist the patient in transferring to the unit for close observation after surgery.
Most children will then be transferred back to the ward within 24 hours.
• If cases of children,they are often able to start eating and drinking again on the
day of the surgery. Until this time they will have a ‘drip’ to provide their fluids
and prevent dehydration.
• Discuss the administration of painkillers to the patient.Pain killers can be given
through a special drip, as suppositories and/or as medicine
• Monitor chest drain. Make sure that the patient does not mobilize too much.
This is to prevent complications developing.
• Instruct the patient avoid taking a bath but would resume to the 3rd or 5th day.
This is to stabilize body mechanisms after the surgery.

DRUGS

1. ACETYLCESTEINE
Acetadote,
Mucomyst

CLASSIFICATION:
Mucolytic, Pregnancy category B

MECHANISM OF ACTION:

Reduces the viscosity of purulent and nonpurulent pulmonary secretions and facilitates
their removal by splitting disulfide bonds.

INDICATIONS:

-chronic emphysema -use with caution in

-emphysema with elderly and clients
-Bronchitis with asthma, sensitivity to drug, lactation
-tuberculosis
-chronic asthmatic
SIDE EFFECTS:

Bronchial/tracheal, irritation, N&V, rash,stomatitis

NURSING RESPONSIBILITY:

-Use nonreactive plastic, glass, or stainless steel for administration.

-After prolonged nebulisation, dilute tha last fourth of the medication with sterile water to
prevent drug concentration.

-Note pulmonary findings: determine when spasm occur.

- Note for Heart failure, paroxysmal supraventricular tachycardia, atrial fibrillation and
flutter.

-monitor patient reaction to drug

2,) Phenytoin/Dilantin
Infatab,
Dilantin-125

CLASS

Antiarrhythmic, Class IB
Anticonvulsant, hydantoin
-Pregnancy category C

MECHANISM OF ACTION:

Acts in the motor cortex of the brain to reduce the spread of electrical discharges from
the rapidly firing epileptic foci in this area.

INDICATIONS:

-Chronic epilepsy - sinus bradycardia

- control sei zures - Lactation
during neurosurgery
- Severe -acute, intermittent porphyria clients with
preeclampsia a history of asthma or
other allergies
-hypersensitivity to - impaired renal or hepatic function
hydantoins - heart disease (hypotension, severe
- exfoliative dermatitis myocardial insufficiency)

SIDE EFFECTS:
Ataxia, drowsiness, slurred speech, confusion, N&V, rash, constipation/ diarrhea,
gingival hyperplasia

NURSING RESPONSIBILITY:

- List reasons for therapy, onset, characteristics of S&S, clinical presentation, blood levels,
other agents trialed, outcome.
- Note history and nature of seizures, addressing location, frequency, duration,
causes/characteristics, triggers and EEG findings.
- Do not substitute products or exchange brands; bioavailability of phenytoin may vary.

-Cleanse area before application of dermatologic preparations.

-Ensure adequate hydration of patient before and during therapy

3.) Gentamicin Sulfate

Brand Name:Garamycin

CLASSIFICATION:
Functional Classification:Antibiotic
Chemical Classification:aminoglycoside

MECHANISM OF ACTION: Inhibits protein synthesis in susceptible strains of gram-

negative bacteria; appears to disrupt functional integrity of bacterial cell membrane,
causing cell death.

INDICATIONS:
Parenteral
• Serious infections caused by susceptible strains of Pseudomonas aeruginosa,
Proteus species, Escherichia coli, Klebsiella-Enterobacter-Serratia species,
Citrobacter, Staphylococcus species
• Serious infections when causative organisms are not known (often in
conjunction with a penicillin or cephalosporin)
• Unlabeled use: With clindamycin as alternative regimen in PID
Intrathecal
• Gram-negative infections
• Serious CNS infections caused by susceptible Pseudomonas species
Ophthalmic preparations
• Treatment of superficial ocular infections due to strains of microorganisms
susceptible to gentamicin
Topical dermatologic preparation
• Infection prophylaxis in minor skin abrasions and treatment of superficial
infections of the skin due to susceptible organisms amenable to local treatment
Gentamicin-impregnated PMAA beads on surgical wire
• Orphan drug use: Treatment of chronic osteomyelitis of post-traumatic,
postoperative, or hematogenous origin
Gentamicin liposome injection
• Orphan drug use: Treatment of disseminated Myobacterium avium-
intracellulare infection

SIDE EFFECTS:
• CNS: Ototoxicity—tinnitus, dizziness, vertigo, deafness (partially reversible to
irreversible), vestibular paralysis, confusion, disorientation, depression,
lethargy, nystagmus, visual disturbances, headache, numbness, tingling,
tremor, paresthesias, muscle twitching, seizures, muscular weakness,
neuromuscular blockade
• CV: Palpitations, hypotension, hypertension
 • GI: Hepatic toxicity, nausea, vomiting, anorexia, weight loss, stomatitis,
increased salivation
• GU: Nephrotoxicity
• Hematologic: Leukemoid reaction, agranulocytosis, granulocytosis,
leukopenia, leukocytosis, thrombocytopenia, eosinophilia, pancytopenia,
anemia, hemolytic anemia, increased or decreased reticulocyte count,
electrolyte disturbances
• Hypersensitivity: Purpura, rash, urticaria, exfoliative dermatitis, itching
• Local: Pain, irritation, arachnoiditis at IM injection sites
Ophthalmic preparations
• Local: Transient irritation, burning, stinging, itching, angioneurotic edema,
urticaria, vesicular and maculopapular dermatitis
Topical dermatologic preparations
• Local: Photosensitization, superinfections

NURSING RESPONSIBILITY:
• Give by IM route if at all possible; give by deep IM injection.
• Culture infected area before therapy.
• Use 2 mg/mL intrathecal preparation without preservatives, for intrathecal use.
• Avoid long-term therapies because of increased risk of toxicities. Reduction in
dose may be clinically indicated.
• Patients with edema or ascites may have lower peak concentrations due to
expanded extracellular fluid volume.
• Cleanse area before application of dermatologic preparations.
• Ensure adequate hydration of patient before and during therapy.
Monitor renal function tests, CBCs, serum drug levels during long-term therapy. Consult with
prescriber to adjust dosage

4.) Captopril

CLASSIFICATION: Therapeutic: Antihypertensives

Pharmacologic: ACE inhibitors

MECHANISM OF ACTION: ACE inhibitors block the conversion of angiotensin I to the

vasoconstrictor angiotensin II. ACE also inactivates the vasodilator bradykinin and other
vasodilatory prostaglandins. ACE inhibitors also increase plasma renin levels and reduce
aldosterone levels. Net result is systemic vasodilation.

INDICATIONS:

 Alone or with other agents in the management of hypertension,

 Management of CHF
 Reduction of risk of death or development of CHF following MI
Slowed progression of left ventricular dysfunction into overt heart failure (selected agents)
Decreased progression of diabetic nephropathy

SIDE EFFECTS:
CNS: dizziness, fatigue, headache, insomnia, weakness.
Resp: cough , eosinophilic pneumonitis.
CV: hypotension , angina pectoris, tachycardia.
GI: taste disturbances , anorexia, diarrhea, nausea.
GU: proteinuria , impotence, renal failure.
Derm: rashes.
F and E: hyperkalemia.
Hemat: AGRANULOCYTOSIS , NEUTROPENIA (captopril only) .
Misc: ANGIOEDEMA , fever.

NURSING RESPONSIBILITIES:

• Inspect IM and IV injection sites frequently for signs of phlebitis.

• Report onset of loose stools or diarrhea. Although pseudo membranous
colitis.
• Monitor I&O rates and pattern: Especially important in severely ill
patients receiving high doses. Report any significant changes.
• Prior to reconstitution, protect drug from light.
The power and reconstituted drug may darken without affecting potency.
• Continue therapy for at east 10 days in infections due to Streptococcus
• pyogenes

5.) PILOCARPINE
(SALAGEN)

CLASSIFICATION: Cholinergic agent, ophthalmic agent, miotic and antiglaucoma

MECHANISM OF ACTION: Pilocarpine is a cholinergic parasympathomimetic agent. It

increases secretion by the exocrine glands, and produces contraction of the iris sphincter
muscle and ciliary muscle (when given topically to the eyes) by mainly stimulating
muscarinic receptors.

INDICATIONS:
1) the treatment of symptoms of dry mouth from salivary gland hypofunction caused
by radiotherapy for cancer of the head and neck; and 2) the treatment of symptoms
of dry mouth in patients with Sjogren's Syndrome.

SIDE EFFECTS:

Body as a whole: body odor, Digestive: anorexia, increased appetite,

hypothermia, mucous membrane esophagitis, gastrointestinal disorder,
abnormality tongue disorder

Cardiovascular: bradycardia, ECG Hematologic: leukopenia,

abnormality, palpitations, syncope lymphadenopathy

Nervous: anxiety, confusion, depression,

abnormal dreams, hyperkinesia,
hypesthesia, nervousness, parethesias, Special senses: deafness, eye pain,
speech disorder, twitching glaucoma

Respiratory: increased sputum, stridor, Urogenital: dysuria, metrorrhagia,

yawning urinary impairment

Skin: seborrhea

NURSING RESPONSIBILITY:
• Patients with edema or ascites may have lower peak concentrations due to
expanded extracellular fluid volume.
• Cleanse area before application of dermatologic preparations.
• Ensure adequate hydration of patient before and during therapy.
• Monitor renal function tests, CBCs, serum drug levels during long-term therapy.
Consult with prescriber to adjust dosage.
• Apply ophthalmic preparations by tilting head back; place medications into
conjunctival sac and close eye; apply light pressure on lacrimal sac for 1 min.
Cleanse area before applying dermatologic preparations; area may be covered
if necessary.