Summary ADVANCED CLINICAL CONCEPTS HESI HINTS DOCUMENT

• 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 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 - Digitalis preparations: Increase the contractility of the heart muscle - Vasoconstrictors (Levophed, Dopamine): Generalized vasonconstriction to provide more available blood to the heart to help maintain cardiac output. • A common volume-expanding substance is plasma and possibly whole blood. • You are caring for a woman who was in severe automobile accident several days ago. She has several fractures and internal injuries. The exploratory laparotomy was successful in controlling the bleeding. However, today you find that this client is bleeding from her incision, short of breath, has a weak thready pulse, has cold and clammy skin, and hematuria. - What do you think is wrong with the client, and what would you expect to do about it? - These are typical signs and symptoms of DIC crisis. Expect to administer IV heparin to block the formation of thrombin (Coumadin does not do this). However, the client described is already past the coagulation phase and into the hemorrhagic phase. Her management would be administration of clotting factors along with palliative treatment of the symptoms as they arise. (Her prognosis is poor). • NCLEX-RN questions on CPR often deal with prioritization of actions. Question: What actions are required for each of the following situations? - A 24-year old motorcycle accident vistim with a ruptured artery if the leg is pulseless and apneic. - A 36-year old first time pregnant woman who arrests during labor. - A 17-year old with no pulse or respirations who is trapped in an overturned car, which is starting to catch fire. - A 40-year old businessman who arrests two days after a cervical laminectomy. • WHEN TO SEEK EMERGENCY MEDICAL SERVICE (EMS) - The American Heart Association recommends that those with known angina pectoris seek emergency medical care if chest pain is NOT relieved by three nitroglycerin tablets 5 minutes apart over a 150minute period. - A person with previously unrecognized coronary disease experiencing chest pain persisting for 2 minutes or longer should seek emergency medical treatment. • It is important for the nurse to stay current with the American Heart Association’s guidelines for Basic Life Support (BLS) by being certified every two years as required. • If one rescuer is performing CPR, 1 15:2 ratio of compression to ventilations is performed for 4 cycles, then reassess for breathing and pulse. If two rescuers are performing CPR, a 15:2 ratio is now recommended for compressions to ventilations. Perform for 15 cycles with a 100/min compression rate. When trading off, start with compressions. • Initiate CPR with BLS guidelines immediately, then move on to Advanced Cardiac Life Support (ACLS) guidelines. • When significant arterial acidosis is noted, try to reduce PCO2 by increasing ventilation, which will correct arterial, venous, and tissue acidosis. Bicarbonate may exacerbate acidosis b producing CO2. Thus, the ACLS guidelines have recommended bicarbonate NOT be used unless hyperkalemia and/or preexisting acidosis is documented. • Infants/prematures may have problems with the following that can predispose to arrest: Beware of the “H’s” – hypoxia, hypoglycemia, hypothermia, increased H+ (metabolic and/or respiratory acidosis), hypercoagulability (if polycythemia exists). • Changes is osmolarity cause shifts in fluid. The osmolarity of the extracellular fluid (ECF) is almost entriely due to sodium. The osmolarity of intracellular fluid (ICF) is related to many particles, with potassium being the primary electrolyte. The pressures in the ECF and the ICF are almost identical. If either ECF or ICF change in concentration, fluid shifts from the area of lesser concentration to the area of greater concentration. • Dextrose 10% is a hypertonic solution and should be administered IV. • Normal saline is an isotonic solution and is used for irrigations, such as bladder irrigations or IV flush lines with intermittent IV medication. • Use only isotonic (neutral) solutions in irrigations, infusions, etc., unless the specific aim is to shift fluid into intracellular or extracellular spaces. • Potassium imbalances are potentially life-threatening, must be corrected immediately. A low magnesium often accompanies a low K+, especially with the use of diuretics. • Fluid Volume Deficit: Dehydration - Elevated BUN: The BUN measures the amount of urea nitrogen in the blood. Urea is formed in the liver as the end product of protein metabolism. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidneys. - Creatinine, as with BUN, is excreted entirely by the kidneys and is therefore directly proportional to renal excretory function. However, unlike BUN, the creatinine level is affected very little by dehydration, malnutrition, or hepatic function. The daily production of creatinine depends on muscle mass, which fluctuates very little. Therefore, it is a better test of renal function than is the BUN. Creatinine is generally used in conjunction with the BUN test and they normally are in a 1:20 ratio. - Serum osmolality measures the concentration of particles in a solution. It refers to the fact that the same amount of solute is present, but the amount of solvent (fluid) is decreased. Therefore, the blood can be considered “more concentrated.” - Urine osmolality and specific gravity increase. • Check the IV tubing container to determine the drip factor because drip factors vary. The most common drip factors are 10, 12, 15, and 60 drops per milliliter. A microdrip is 60 drops per milliliter. • Flushing a saline lock requires approximately 1 ½ times the amount of fluid that the tubing will hold in order to efficiently flush the tubing. REMEMBER to use sterile technique to prevent complications such as infiltration, emboli and infection. • A pH of less than 6.8 or more than 7.8 is NOT COMPATIBLE WITH LIFE. • The acronym ROME can help you remember: Respiratory, Opposite, Metabolic, Equal. • Review the order of blood flow to the heart: - Unoxygenated blood flows from the superior and inferior vena cava into the right atrium, then to the right ventricle. It flows out of the heart through the pulmonary artery, to the lungs for oxygenation. The pulmonary vein delivers oxygenated blood back to the left atrium, then to the left ventricle (largest, strongest chamber) and out the aorta. - Review the three structures that control the one-way flow of blood through the heart: 1. Valves Atrioventricular valves  Tricuspid (right side)  Mitral (left side) Semilunar valves  Pulmonary (in pulmonary artery)  Aortic (in aorta) 2. Cordae Tendinae 3. Papillary muscles • Since the T waves represents repolarization of the ventricle, this is a critical time in the heartbeat. This action represents a resting and regrouping stage so that the next heartbeat can occur. If defibrillation occurs during this phase, the heart can be thrust into a life-threatening dysrhythmia. • Observe the client for tolerance of the current rhythm. This information is the most important data the nurse can collect on the client with an arrythmia. • REMEMBER to monitor the client as well as the machine! If the EKG monitor shows a severe dysrhythmia, but the client is sitting up quietly watching a TV without any sign of distress, assess to determine if the leads are attached properly. • Marking the operative site is required for procedures involving right/left distinctions, multiple structures (fingers, toes), or levels (spinal procedures). Site marking should be done with the involvement of the client. • Wound dehiscence is separation of the wound edges and is more likely to occur with vertical incisions. It usually occurs after the early postoperative period, when the client’s own granulation tissue is “taking over” the wound, after absorption of the sutures has begun. Evisceration of the wound is protrusion of intestinal contents (in an abdominal wound) and is more likely in clients who are older, diabetic, obese, or malnourished and have prolonged paralytic ileus. • NCLEX-RN items will focus on the nurse’s role in terms of the entire perioperative process. Sample: A 43-year old mother of 2 teenage daughters enters the hospital to have her gallbladder removed in a same-day surgery using a scope instead of an incision. What nursing needs will dominate each phase of her short hospital stay? - Preparation phase: Education about postoperative care, NPO, assist with meeting family needs. - Operative phase: Assessment, management of the operative suite. - Post-anesthesia phase: Pain management, post-anesthesia precautions. - Post-operative phase: Prevent and assess for complications, pain management, dietary restrictions, activity. • HIV clients with tuberculosis require respiratory isolation. Tuberculosis is the only real risk to non-pregnant caregivers that is not related to a break in universal precautions (i.e., needle sticks, etc.). • STANDARD PRECAUTIONS: - Wash hands, even if gloves have been worn to give care - Wear gloves (latex) for touching blood or body fluids, or any non-intact body surface. - Wear gowns during any procedure that might generate splashes (changing clients with diarrhea). - Use masks and eye protection during activity which might disperse droplets (suctioning). - Do not recap needles, dispose of in puncture-resistant containers. - Use mouth piece for resuscitation efforts. - Refrain from giving care if you have open skin lesions. • Caregivers who are pregnant may choose not to care for a client with Cytomegalovirus (CMV). • Pediatric HIV is often evidenced by lymphoid interstitial pneumonitis. • The focus of NCLEX-RN questions is likely to be assessment of early signs of the disease and management of complications associated with HIV. • For narcotic induced respiratory depression, administer Naloxone 0.1mg to 0.4mg IV every 2-3 minutes as needed, until 1.0mg is achieved. • Use non-invasive methods for pain management when possible: - Relaxation techniques - Distraction - Imagery - Biofeedback - Interpersonal skills - Physical care: altering positions, touch, hot and cold applications. • Narcotic analgesics are prepared for pain relief because they bind to the various opiate receptor sites in the CNS. Morphine is often the preferred narcotic (REMEMBER: it causes respiratory depression). • Other agonists are meperidine and methadone. Narcotic antagonists block the attachment of narcotics to the receptors, such as Narcan (naloxone). Once Narcan has been given, additional narcotics cannot be given until the Narcan effects have passed. • Do not take away the coping style used in a crisis state… DENIAL. It is a useful and needed tool at the initial stage for some. Support, do not challenge, unless it hinders/blocks treatment – endangering the patient. MEDICAL –SURGICAL NURSING RESPIRATORY SYSTEM • Fever can cause dehydration from excessive fluid loss in diaphoresis. Increased temperature also increases metabolism and the demand for oxygen. • High risk for pneumonia: - Any person, who has altered level of consciousness, has depressed or absent gag reflex and cough reflexes, is susceptible to aspirating oropharyngeal secretions. (Alcoholics, anesthesized individuals, those with brain injury, drug overdose, or stroke victims). - When feeding, raise the head of the bed and position the client on side – not on back. • Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue. • Hydration – enables liquification of mucous trapped in the bronchioles and alveoli, facilitating expectoration. Essential for the client experiencing fever. Important because 300 to 400 ml of fluid are lost daily by the lungs through evaporation. • Irritability and restlessness are early signs of cerebral hypoxia – the client is not getting enough oxygen to the brain. • Pneumonia preventatives: - Elderly: flu shots; pneumonia immunizations; avoiding sources of infection and indoor pollutants (dust, smoke, and aerosols); do not smoke. - Immunosuppressed and debilitated persons: infection avoidance, sensible nutrition, adequate intake, balance of rest and activity. - Comatose and immobile persons: elevate head of bed to feed; turn frequently. • Compensation occurs over time in clients with chronic lung disease, and arterial blood gases (ABGs) are altered. It is imperative that baseline data are obtained on the client. • Productive cough and comfort can be facilitated by Semi- Fowler’s or high Fowler’s positions, which lessen pressure on the diaphragm from abdominal organs. Gastric distention becomes a priority in these clients because it elevates the diaphragm and inhibits lung expansion. • Pink puffer: Barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe, which causes the person to work harder to breathe, but the amount of O2 taken in in adequate to oxygenate the tissues.