ADVANCED CLINICAL CONCEPTS
• ARDS is an unexpected, catastrophic pulmonary complication occurring in a person with no
previous pulmonary problems. The mortality rate is high (50%)
• In ARDS, a common laboratory finding is lowered PO2. However, these clients are not very
responsive to high concentrations of oxygen.
• Think about the physiology of the lungs by remembering PEEP: Positive End Expiratory Pressure
is the instillation and maintenance of small amounts of air into the alveolar sacs to prevent them
from collapsing each time the client exhales. The amount of pressure can be set with the
ventilator and is usually around 5 to 10 cm of water.
• Suction only when secretions are present.
• Before drawing arterial blood gases from the radial artery, perform the Allen test to assess
collateral circulation. Make the client’s hand blanch by obliterating both the radial and ulnar
pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is
good, flushing will be seen immediately. The Allen test is then positive, and the radial artery can
be used for puncture. If the Allen test is negative, repeat on the other arm. If this test is also
negative, seek another site for arterial puncture. The Allen test ensures collateral circulation to
the hand if thrombosis of the radial artery should follow the puncture.
• If the client does not have O2 to his/her brain, the rest of the injuries do not matter because
death will occur. However, they must be removed from any source of imminent danger,such as a
fire.
• PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory failure.
• A child in severe distress should be on 100% O2.
• Early signs of shock are agitation and restlessness resulting from cerebral hypoxia.
• If cardiogenic shock exists with the presence of pulmonary edema, i.e., from pump failure,
position client to REDUCE venous return (HIGH FOWLER’s with legs down) in order to decrease
venous return further to the left ventricle.
• Severe shock leads to widespread cellular injury and impairs the integrity of the capillary
membranes. Fluid and osmotic proteins seep into the extra vascular spaces, further reducing
cardiac output. A v vicious cycle of decreased perfusion to ALL cellular level activities ensues. All
organs are damaged, and if perfusion problems exist, the damage can be permanent.
• All vasopressors/vasodilator drugs are potent and dangerous and require weaning on and off.
Do not change infusion rates simultaneously.
• A client is brought into the hospital suffering shock symptoms as a result of a bee sting. What is
the first priority? Maintaining an open airway (the allergic reaction damages the lining of the
airways causing edema). Also, keep the client warm without constricting clothing; keep legs
elevated (not Trendelenburg because the weight of the lower organs restricts breathing).
• Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild
• Epinephrine: 1:10,000, or 5ml IV for severe
• Volume expanding fluids are usually given to clients in shock. However, if the shock is
cardiogenic, pulmonary edema may result.
• Drugs of choice for shock
• ARDS is an unexpected, catastrophic pulmonary complication occurring in a person with no
previous pulmonary problems. The mortality rate is high (50%)
• In ARDS, a common laboratory finding is lowered PO2. However, these clients are not very
responsive to high concentrations of oxygen.
• Think about the physiology of the lungs by remembering PEEP: Positive End Expiratory Pressure
is the instillation and maintenance of small amounts of air into the alveolar sacs to prevent them
from collapsing each time the client exhales. The amount of pressure can be set with the
ventilator and is usually around 5 to 10 cm of water.
• Suction only when secretions are present.
• Before drawing arterial blood gases from the radial artery, perform the Allen test to assess
collateral circulation. Make the client’s hand blanch by obliterating both the radial and ulnar
pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is
good, flushing will be seen immediately. The Allen test is then positive, and the radial artery can
be used for puncture. If the Allen test is negative, repeat on the other arm. If this test is also
negative, seek another site for arterial puncture. The Allen test ensures collateral circulation to
the hand if thrombosis of the radial artery should follow the puncture.
• If the client does not have O2 to his/her brain, the rest of the injuries do not matter because
death will occur. However, they must be removed from any source of imminent danger,such as a
fire.
• PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory failure.
• A child in severe distress should be on 100% O2.
• Early signs of shock are agitation and restlessness resulting from cerebral hypoxia.
• If cardiogenic shock exists with the presence of pulmonary edema, i.e., from pump failure,
position client to REDUCE venous return (HIGH FOWLER’s with legs down) in order to decrease
venous return further to the left ventricle.
• Severe shock leads to widespread cellular injury and impairs the integrity of the capillary
membranes. Fluid and osmotic proteins seep into the extra vascular spaces, further reducing
cardiac output. A v vicious cycle of decreased perfusion to ALL cellular level activities ensues. All
organs are damaged, and if perfusion problems exist, the damage can be permanent.
• All vasopressors/vasodilator drugs are potent and dangerous and require weaning on and off.
Do not change infusion rates simultaneously.
• A client is brought into the hospital suffering shock symptoms as a result of a bee sting. What is
the first priority? Maintaining an open airway (the allergic reaction damages the lining of the
airways causing edema). Also, keep the client warm without constricting clothing; keep legs
elevated (not Trendelenburg because the weight of the lower organs restricts breathing).
• Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild
• Epinephrine: 1:10,000, or 5ml IV for severe
• Volume expanding fluids are usually given to clients in shock. However, if the shock is
cardiogenic, pulmonary edema may result.
• Drugs of choice for shock
