Exam 1: NSG233/ NSG 233 (Latest 2023/ 2024 Update) Med Surg 3 Exam| Guide with Questions and Verified Answers| 100% Correct- Herzing

Exam 1: NSG233/ NSG 233 (Latest 2023/ 2024 Update) Med Surg 3 Exam| Guide with Questions and Verified Answers| 100% Correct- Herzing

Exam 1: NSG233/ NSG 233 (Latest 2023/
2024 Update) Med Surg 3 Exam| Guide with
Questions and Verified Answers| 100%
Correct- Herzing
Q: Triage patients in the ED
Answer:
Use ESI (emergency severity index) tool
Responsibilities of triage nurse:
Assess, reassess, initiate treatment, manage and communicate, edu tients, transport them
Q: Meds for managing sexual assault
Answer:
Prophylaxis for gonorrhea
Ceftriaxone + 1% lidocaine
Prophylaxis for syphilis and chlamydia: Single dose metronidazole
Single dose azithromycin
7-day oral regimen doxycycline
Anti-pregnancy:
Levonorgestrel and ethinyl estradiol
Give within 12-24 hours, no more than 72 hours post-intercourse
Antiemetic for side effects
Q: Tension pneumothorax care
Answer:
Immediate needle decompression
Followed by chest tube insertion
S/S: chest pain, dyspnea, tachycardia, anxiety, air hunger, increased use of acces- sory muscles,
decreased/absent breath sounds on affected side, deviated trachea to unaffected side

Q: Subcutaneous emphysema care
Answer:
Leaked air pockets under skin, feels like
“rice crispies”
Part of spontaneous pneumothorax
Not usually serious Report to provider Monitor airway
Absorbs once pneumothorax is treated
Q: Intra-abdominal injury care
Answer:
Risk for hemorrhage – monitor for shock
Liver – right shoulder pain
Spleen – left shoulder pain
If stable –> CT
If unstable –> FAST exam (focused assessment with sonography for trauma) Management:
ABCs, C-spine precautions, NPO, antibiotics/tetanus, monitoring, surgery PRN
Q: Pneumothorax assessment
Answer:
Tracheal alignment – midline (simple pneumoth- orax)
Chest expansion – decreased
Breath sounds – diminished/absent
Chest percussion – normal/hyper-resonant
Q: Pneumothorax care
Answer:
Goal: to evacuate air/blood from pleural space
A small chest tube (28 Fr) is inserted near second intercostal space
If hemothorax, large tube (32 Fr or greater) is inserted in fourth or fifth intercostal space
Suction is applied

Pleural cavity is decompressed (drainage of air/blood)
Q: Patient-controlled analgesia (PCA)
Answer:
Has programmable settings
Delivers morphine at a preset bolus
Can program a lockout period (control frequency)
HCP gives loading dose to attain therapeutic blood levels quickly (with continuous
IV infusion)
Assess pain scores after initiation, after any change in pump setting, and periodically
Q: Assessment for appropriateness of PCA
Answer:
Pre-procedure cognitive assess- ment
If opioid-tolerant* or opioid-naive* Pain assessment
Sedation assessment (precedes resp depression) Respiratory assessment
*Tolerant – 60 mg for a week or longer
*Naive – less than tolerant criteria
Q: Crush injuries
Answer:
At risk for rhabdomyolysis (crush syndrome) and compartment syndrome
Observe for: Hypovolemic shock Spinal cord injury
Erythema and skin blistering
Fractures
Acute kidney injury (from acute tubular necrosis)
Q: Rhabdomyolysis
Answer:
Destroyed skeletal muscle cells empty contents into circula- tion, causing kidney problems
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Potassium administration
Mix with 120 mL water or juice
Don’t crush/chew
Take after meals initially, then before meals if no n/v
Don’t suddenly stop taking it
Don’t use salt substitutes
Recognize S/S of hypo/hyperkalemia
Never give undiluted by IV or IV push

S/S hyperkalemia
Slow pulse, fatigue, SOB

*both hypo & hyper have palpitations, confusion, and muscle weakness

S/S hypokalemia
Dizziness, abdominal distension, frequent voiding

*both hypo & hyper have palpitations, confusion, and muscle weakness

Antidote for ingested poisons
Activated charcoal
Decreases poison absorption
Give within first hour for effectiveness

Management of ingested poisons
Priority: airway stabilization
Control of airway, ventilation, and oxygen
Determine what was ingested, time since ingestion, S/S (pain, burning sensation, redness/burn in mouth, throat, pain on swallowing or inability to swallow, vomiting, drooling)
Age & weight of patient
Pertinent health history

S/S carbon monoxide poisoning
Headache, dizziness, confusion, palpitations, muscle weakness, intoxication –> coma, death

Management of carbon monoxide poisoning
Priority – assess carboxyhemoglobin levels
Treat with 100% O2
May need hyperbaric chamber

Meds to treat overdose
Activated charcoal (“universal” antidote)
Acetylcysteine for acetaminophen
Benzos for alcohol withdrawal/delirium tremens
Atropine for cholinergic drugs (rivastigmine, polocarpine, donepezil, neostigmine, etc)

No longer used: Ipecac-induced vomiting or gastric lavage (minimal effectiveness & potential complications)

Alcohol withdrawal treatments
Sedate with benzos (reduce agitation, exhaustion, seizures, promotes sleep)
Calm environment
Physical exam to identify pre-existing illness/injury
Drug history
Baseline BP

Treatment of Intimate Partner Violence
Refer to resources
Try to separate them
Can’t report unless child/elderly
Document wounds

Triage patients in the ED
Use ESI (emergency severity index) tool

Responsibilities of triage nurse:
Assess, reassess, initiate treatment, manage and communicate, educate, sort patients, transport them

Meds for managing sexual assault
Prophylaxis for gonorrhea

Ceftriaxone + 1% lidocaine

Prophylaxis for syphilis and chlamydia:

Single dose metronidazole

Single dose azithromycin

7-day oral regimen doxycycline

Anti-pregnancy:

Levonorgestrel and ethinyl estradiol

Give within 12-24 hours, no more than 72 hours post-intercourse

Antiemetic for side effects

Tension pneumothorax care
Immediate needle decompression
Followed by chest tube insertion
S/S: chest pain, dyspnea, tachycardia, anxiety, air hunger, increased use of accessory muscles, decreased/absent breath sounds on affected side, deviated trachea to unaffected side

Subcutaneous emphysema care
Leaked air pockets under skin, feels like “rice crispies”
Part of spontaneous pneumothorax
Not usually serious
Report to provider
Monitor airway
Absorbs once pneumothorax is treated

Intra-abdominal injury care
Risk for hemorrhage – monitor for shock
Liver – right shoulder pain
Spleen – left shoulder pain
If stable –> CT
If unstable –> FAST exam (focused assessment with sonography for trauma)
Management: ABCs, C-spine precautions, NPO, antibiotics/tetanus, monitoring, surgery PRN

Pneumothorax assessment
Tracheal alignment – midline (simple pneumothorax)
Chest expansion – decreased
Breath sounds – diminished/absent
Chest percussion – normal/hyper-resonant

Pneumothorax care
Goal: to evacuate air/blood from pleural space
A small chest tube (28 Fr) is inserted near second intercostal space
If hemothorax, large tube (32 Fr or greater) is inserted in fourth or fifth intercostal space
Suction is applied
Pleural cavity is decompressed (drainage of air/blood)

Patient-controlled analgesia (PCA)
Has programmable settings
Delivers morphine at a preset bolus
Can program a lockout period (control frequency)
HCP gives loading dose to attain therapeutic blood levels quickly (with continuous IV infusion)
Assess pain scores after initiation, after any change in pump setting, and periodically

Assessment for appropriateness of PCA
Pre-procedure cognitive assessment
If opioid-tolerant or opioid-naive
Pain assessment
Sedation assessment (precedes resp depression)
Respiratory assessment

*Tolerant – 60 mg for a week or longer
*Naive – less than tolerant criteria

Crush injuries
At risk for rhabdomyolysis (crush syndrome) and compartment syndrome

Observe for:
Hypovolemic shock
Spinal cord injury
Erythema and skin blistering
Fractures
Acute kidney injury (from acute tubular necrosis)

Rhabdomyolysis
Destroyed skeletal muscle cells empty contents into circulation, causing kidney problems
S/S: muscle pain & weakness, elevated CK, dark brown urine
Can lead to acute kidney failure (Tx: Fluids)

Compartment syndrome
Increased pressure within muscle compartments
Extreme pain, decreased/absent CMS (circulation, motor, sensory)
Leads to decreased perfusion –> loss of limb
Tx: Fasciotomy

Treatment of hypovolemic shock
Stop loss of fluid
Replace fluid
Two large-bore IVs (18 G)
0.9% NS, whole blood, or PRBCs
Warm fluids with massive transfusions to prevent hypothermia

Treatment of cardiogenic shock
Fix cause (stent placement, thrombolytics for MI)
Decrease preload (diuretics, venous vasodilators)
Decrease SVR* (arterial vasodilators, balloon pump, LVAD – left ventricular assist device)
Decrease HR (digoxin, b-blockers)
Increase contractility (digoxin, dopamine)

*systemic vascular resistance

Treatment of obstructive shock
Correct obstruction
Pneumothorax: needle decompression/chest tube
PE: embolectomy
Abdominal compartment syndrome: laparotomy
Cardiac tamponade: pericardiocentesis (drain fluid from heart sac)

Treatment of septic shock
Collect blood cultures
Broad-spectrum IV antibiotics, then narrow after organism ID’ed
0.9% NS for hypotension –> fix preload
Vasopressors if not responsive to fluids –> fix afterload
Anticoagulants to prevent DIC*

*disseminated intravascular coagulation (clotting & bleeding)

Treatment of neurogenic shock
Prevent further damage by cervical spine and back stabilization
Maintain patent airway and assist with breathing PRN
Cautious fluid resuscitation (preload)
Vasopressors –> increase BP (afterload)
Atropine –> increase HR

Stages of Shock
Stage 1 – Compensatory
Stage 2 – Progressive
Stage 3 – Irreversible

Shock – Compensatory Stage
Mild decrease in BP triggers autonomic nervous system and RAAS to compensate
ANS –> increase epi/norepi –> increase BP
also releases cortisol –> increase BG
RAAS –> release renin & aldosterone –> vasconstriction & fluid/Na+ retention –> increase BP

Laura:

100 bpm
20 breaths/min
PaCO2 <32
Cold, clammy skin
Confused/agitated
Respiratory alkalosis (deep rapid breathing, lightheaded, n/v, muscle twitching)

Shock – Progressive stage
BP becomes low enough that body can’t compensate anymore
MAP decreased
lack of O2 to heart –> ischemia and impaired pumping
Capillary leakage –> hypovolemia
Metabolic acidosis

Laura:
Systolic <90 MAP < 65 Fluid resuscitation required for BP HR >150 bpm
Rapid, shallow respirations, crackles
Lethargy
PaO2 < 80, PaCO2 > 45

Shock – Irreversible stage
Profound hypotension, hypoxemia, acidosis
Requires mechanical ventilation & vasopressors
MODS (multiple organ dysfunction syndrome)
Family care conference to plan for end of life

S/S of patient in shock
Increased RR (compensation for decreased O2 in blood)
Decreased BP (MAP)
Increased HR (compensate for decreased BP)
Decreased urine output (decreased kidney perfusion)
Increased BG (from release of cortisol)
Cool, clammy skin (from release of epi/norepi –> shunting of blood to core)

Assessing flail chest
From blunt chest trauma (i.e. steering wheel injury)
Detached rib pulled inward during inspiration, reduces air drawn into lungs
Impaired ability to exhale due to intrathoracic pressure > atmospheric pressure
Mediastinum shifted to affected side

Managing flail chest
Pain control (nerve blocks over opioids)
Clear secretions (IS, chest physiotherapy)
Pulse ox, serial chest x-rays, ABGs
Ventilator support (in severe cases)

Assessing hypovolemic shock
Caused by inadequate fluid volume

Absolute hypovolemia – external loss (hemorhage, diuresis, GI loss)

Relative hypovolemia – internal loss (fluid shifts, internal bleeding)

Dec CO –> dec tissue perfusion –> impaired cell metabolism

Assessing neurogenic shock
Due to disruption of sympathetic nervous system –> loss of sympathetic tone in blood vessels –> vasodilation –> dec BP –> dec tissue perfusion –> impaired cell metabolism

*since SNS is impaired, PNS takes over, pt presents with low HR

Laura: hypotension, bradycardia, dry/warm skin

Treatment for anaphylactic shock
Epinephrine

Treatment for neurogenic shock
•Prevent further damage by cervical spine and back stabilization

•Maintain patent airway and assist with breathing as needed

•Cautious fluid resuscitation (preload)

•Vasopressors for vasoconstriction of blood vessels –> increase BP (afterload)

•Atropine or cardiac pacing for bradycardia –> increase HR

Assessing MODS
When 2 or more organs fail
A complication of any form of shock, most commonly seen with sepsis and inadequate tissue perfusion
Clinical assessment tools:
APACHE
SAPS
PIRO
SOFA

Medications for hypovolemic shock
Adrenergic drugs (epi, norepi)
Insulin if dehydration secondary to hyperglycemia
Desmopressin (DDAVP) for diabetes insipidus
Antidiarrheals, antiemetics

Assessing wounds
Location, size, appearance, color, type, condition, surrounding skin, approximation, drainage, pain, odor, drains, closure devices
Photographs are helpful
Use aseptic technique to determine extent of damage or presence of foreign body
Evaluate sensory, motor, and vascular function for changes that might indicate complications

Nonfatal drowning
Survival > 24 hours post-submersion
Treat aspiration:
Fresh water –> dec gas exchange
Salt water –> PE from osmosis
Dirty water –> infection
At risk for ARDS and ischemic brain injury
Management: ABCs, warming, monitoring

Antivenin administration
Poison control center
Corticosteroids are contraindicated
Give within 4-12 hours as infusion or IM
Most available in US: FabAV or CroFAB
Measure circumference of affected part before administering
Premedicate with diphenhydramine or cimetidine
Monitor for serum sickness (fever, rash, n/v/d, abd pain)

Lyme disease
3 stages:

1. Bulls-eye rash, within 4 weeks, flu-like symptoms
2. Systemic reaction, 4-10 weeks, joint pain, memory loss, poor motor coordination, adenopathy, cardiac abnormalities, facial nerve palsy
3. Long-term chronic symptoms, arthritis, neuropathy, myalgia, myocarditis, fatigue, arthralgia, neuro symptoms

Laceration
Irregular edges and vein bridging

Avulsion
Tearing away of tissue

Abrasion
denuded skin (loss of epidermis)

Ecchymosis/contusion
blood trapped under surface of skin

Hematoma
tumorlike mass of blood trapped under skin

Stab
Well-defined edges, deeper than long

Cut
Well-defined edges, longer than deep

Patterned
represents outline of object causing wound

Emergency triage system
Use of ESI (emergency severity index)
5 levels:

1. Most urgent – serious accident/injury, stopped breathing, heart stopped beating
2. Very urgent – trouble breathing, chest pain, badly broken bones
3. Urgent – asthma, sick baby < 3 mo, temp > 40 C
4. Less urgent – broken ankle, sore throat/eyes/ears, need stitches
5. Not urgent – obtain prescription/certificate, removal of stitches

Trauma assessment – Primary survey
ABCDEFGLMNOP
Airway
Breathing
Circulation
Disability
Exposure/Environmental control
Full set of vitals / Family presence
Get resuscitation adjuncts
Labs
Monitor ECG
NG tube
Oxygen
Pain assessment
*also check for spine & chest injuries
*control hemorrhage, shock, circulation, hypothermia

Trauma assessment – Secondary survey
SAMPLE history
Symptoms
Allergies
Medication history
Past health history
Last oral intake
Events before illness
*HTT assessment
*Inspect posterior surfaces
*Attend to family

Trauma vs Non-Trauma Assesssment
Both have:

1. Initial assessment – ID immediate threats
2. Primary Survey
3. Secondary Survey

Trauma: include HTT assessment
Non-trauma: Focused assessment only

Tetanus prophylaxis
Required for every wound
Booster every 10 years
Again if major wound and last vaccine > 5 yrs
If no history of vaccine: Vaccine + Immunoglobulins

Family Care
Let them see their family member
Appoint a spokesperson for large families
Provide info
Provide reassurance

Heparin antidote
protamine sulfate

Warfarin antidote
Vitamin K

Priority actions for hemorrhage
Control the bleeding, assess patient for s/s of shock

decompression sickness (the bends)
A condition seen in divers in which gas, especially nitrogen, forms bubbles in blood vessels, obstructing them.

Fluid management of hypovolemic shock
Therefore, fluid replacement is imperative to maintain circulation. Typically, two large-gauge IV catheters are inserted, preferably in an uninjured extremity, to provide a means for fluid and blood replacement. Blood samples are obtained for analysis, typing, and cross-matching. Replacement fluids are given as prescribed, depending on clinical estimates of the type and volume of fluid lost. Replacement fluids may include isotonic electrolyte solutions (e.g., lactated Ringer’s, normal saline), colloids, and blood component therapy.

Violence In The ED
atients and family members under the influence of illicit drugs or alcohol, or who may have psychiatric disorders, including delirium or dementia, or who may be influenced by social situations such as gang membership, are at risk for committing a violent act, whether intentional or not (CDC, 2019a). The environment of the ED, including being subjected to long wait times and at times crowded conditions, may also increase their risk of committing violent events. Physical threats are most often accompanied by verbal abuse, which is the most common type of violence (Copeland & Henry, 2017). Although not a typical occurrence, a patient or family member may come to the ED armed. To avoid angry confrontations, members of gangs and families who are feuding need to be separated in the ED, in the waiting room, and later in the inpatient nursing unit. Nurses and other personnel must be prepared to deal with these circumstances. The ED should be locked against entry if security is questionable.
Patients who are violent or potentially violent must be vigilantly monitored by the ED staff. Care must be taken to avoid injury. Patients from prison and those who are under guard need to be handcuffed to the bed and appropriately assessed to ensure the safety of hospital staff and other patients. The emergency nurse must understand how to employ safe use of restraints. The Joint Commission has strict standards regarding documentation of the reason, monitoring for safety, and ensuring the dignity of the patient who is restrained. Precautions to be taken to avoid injury include the following situations (ENA 2020a; Ziaei, Massoudifar, Rajabpour-Sanati, et al., 2018):
•For prisoners, the hand or ankle restraint (handcuff) is never released, and a guard is always present in the room.
•A mask can be placed on the patient to prevent spitting or biting, if a mask is not already being used.
•Nonrestraint techniques should be tried when possible—for example, talking with the patient, minimizing environmental stimulation.
•Physical restraints are used on any patient who is violent only as needed and, if used, should be humanely and professionally given; nonetheless, the staff should be cognizant that the patient could head-butt, even if restrained.
•Distance should be maintained from the patient to avoid grabbing; staff should not wear items that can be grabbed by the patient, such as dangling jewelry and stethoscopes. Furthermore, distance should be maintained between the patient and the door so that an escape route for the staff member is preserved.
•Objects should not be left within patient reach; even an intravenous (IV) line spike can become a tool of violence if the patient is determined.
•Courses on safety (de-escalation and physical restraint techniques) assist the staff with preparing for various violent situations.
In the case of gunfire in the ED, self-protection is a priority. There is no advantage to protecting others if health care providers are injured. Security officers and police must gain control of the situation first, and then care is provided to the injured.

Drugs used in bronchoscopy
In patients requiring endotracheal intubation, neuromuscular blocking agents are used to achieve muscle relaxation. Modern neuromuscular blocking agents, or muscle relaxants, are divided into two classes, non-depolarizing and depolarizing muscle relaxants. Neuromuscular blocking agents facilitate easy tracheal intubation and mechanical ventilation by relaxing the vocal cords, jaw, and associated respiratory muscles. Ex. Vecuronium

Succinylcholine (Anectine, Quelicin) is a rapid onset and short duration muscle relaxant administered by intravenous or intramuscular injection. The depolarization caused by succinylcholine results momentary contractions of the muscles called fasciculation; the patient’s entire body may twitch and move for about 5 to 10 seconds. After the fasciculation, the succinylcholine remains attached to the receptor, and there is muscle paralysis for approximately 5 to 10 minutes. Succinylcholine is metabolized by plasma cholinesterase. There are no reversal medications for succinylcholine.

The primary use for succinylcholine is paralysis for tracheal intubation, especially when it is necessary to quickly protect the airway. When tracheal intubation is combined with cricoid pressure to occlude the esophagus, it is referred to as rapid sequence induction. This type of induction is indicated in emergency procedures that reduces the risk of aspiration when an empty stomach cannot be guaranteed. Succinylcholine is also used to relax the vocal cords and terminate a laryngospasm.

Heat exhaustion
a form of physical stress on the body caused by overheating

Frostbite
damage to the skin and tissues caused by extreme cold

Suture Care

• Close tissue to reduce scar formation, minimize trauma & tension, & control bleeding
• Sutures, staples, steri-strips

Complications of rapid IV infusions
Care must be taken when rapidly administering isotonic crystalloids to avoid both underresuscitating and overresuscitating the patient in shock. Insufficient fluid replacement is associated with a higher incidence of morbidity and mortality from lack of tissue perfusion, whereas excessive fluid administration can cause systemic and pulmonary edema that progresses to ALI, intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), and MODS (see later discussion).
ACS is a serious complication that may occur when large volumes of fluid are given. It may also occur after trauma, abdominal surgery, pancreatitis, or sepsis (Harrell & Miller, 2017). In ACS, fluid leaks into the intra-abdominal cavity, increasing pressure that is displaced onto surrounding vessels and organs. Venous return, preload, and cardiac output are compromised. The pressure also elevates the diaphragm, making it difficult to breathe effectively. The renal and GI systems also begin to show signs of dysfunction (e.g., decreased urine output, absent bowel sounds, intolerance of tube feeding). Abdominal compartment pressure can be measured. Normally, it is 0 to 5 mm Hg, and a pressure of 12 mm Hg is considered to be indicative of IAH (Harrell & Miller, 2017). If ACS is present, interventions that usually include surgical decompression are necessary to relieve the pressure.

Care of septicemia
When caring for a patient with sepsis or septic shock, the nurse collaborates with other members of the health care team to identify the site and source of sepsis and the specific organisms involved. The nurse often obtains appropriate specimens for culture and sensitivity. Prescribed antibiotics are not given until these specimens are obtained. Hyperthermia (elevated body temperature) is common with sepsis and raises the patient’s metabolic rate and oxygen consumption. Efforts may be made to reduce the temperature by administering acetaminophen or applying a hypothermia blanket. During these therapies, the nurse monitors the patient closely for shivering, which increases oxygen consumption. Efforts to increase comfort are important if the patient experiences fever, chills, or shivering.
The nurse administers prescribed IV fluids and medications, including antibiotic agents and vasoactive medications, to restore vascular volume. Because of decreased perfusion, serum concentrations of antibiotic agents that are normally cleared by the kidneys and liver may increase and produce toxic effects. Therefore, the nurse monitors blood levels (serum levels of antibiotic agents, procalcitonin, CRP, BUN, creatinine, WBC count, hemoglobin, hematocrit, platelet levels, coagulation studies) and reports changes to the primary provider. As with other types of shock, the nurse monitors the patient’s hemodynamic status, fluid I&O, daily weight, and nutritional status. Close monitoring of serum albumin and prealbumin levels helps determine the patient’s protein requirements.

Hypothermia Interventions
Management consists of removal of wet clothing, continuous monitoring, rewarming, and supportive care.

Monitoring ABCs
Core body temp is monitored through esophageal, bladder, or rectal

Rewarming methods include active internal (core) rewarming and passive (spontaneous) or active external rewarming

Supportive Care
Supportive care during rewarming includes the following as directed:
External cardiac compression (typically performed only as directed in patients with temperatures higher than 31°C [88°F])
Defibrillation of ventricular fibrillation. A patient whose temperature is less than 32°C [90°F] experiences spontaneous ventricular fibrillation if moved or touched.

Defibrillation is ineffective in patients with temperatures lower than 31°C (88°F); therefore, the patient must be rewarmed first.

Mechanical ventilation with positive end-expiratory pressure (PEEP) and heated humidified oxygen to maintain tissue oxygenation

Administration of warmed IV fluids to correct hypotension and to maintain urine output and core rewarming, as described previously

Administration of sodium bicarbonate to correct metabolic acidosis if necessary

Administration of antiarrhythmic medications

Insertion of an indwelling urinary catheter to monitor urinary output and kidney function

Treating cardiogenic shock
The role of the nurse managing the care of a patient with cardiogenic shock revolves around preventing its serious complications, monitoring hemodynamics, administering medications and fluids, maintaining intra-aortic counterpulsation as indicated, and promoting safety and comfort.

Preventing Cardiogenic Shock

Identifying at-risk patients early, promoting adequate oxygenation of the heart muscle, and decreasing cardiac workload can prevent cardiogenic shock. This can be accomplished by conserving the patient’s energy, promptly relieving angina, and administering supplemental oxygen. Often, however, cardiogenic shock cannot be prevented. In such instances, nursing management includes working with other members of the health care team to prevent shock from progressing and to restore adequate cardiac function and tissue perfusion.

Monitoring Hemodynamic Status

A major role of the nurse is monitoring the patient’s hemodynamic and cardiac status. Arterial lines and ECG monitoring equipment must be well maintained and functioning properly. The nurse anticipates the medications, IV fluids, and equipment that might be used and is ready to assist in implementing these measures. Changes in hemodynamic, cardiac, and pulmonary status and laboratory values are documented and reported promptly. In addition, adventitious breath sounds, changes in cardiac rhythm, and other abnormal physical assessment findings are reported immediately.

Administering Medications and Intravenous Fluids

The nurse plays a critical role in the safe and accurate administration of IV fluids and medications. Fluid overload and pulmonary edema are risks because of ineffective cardiac function and accumulation of blood and fluid in the pulmonary tissues. The nurse documents medications and treatments that are given as well as the patient’s response to treatment.

The nurse must be knowledgeable about the desired effects as well as the side effects of medications. For example, the nurse monitors the patient for decreased BP after administering morphine or nitroglycerin. Arterial and venous puncture sites must be observed for bleeding, and pressure must be applied at the sites if bleeding occurs. IV infusions must be observed closely because tissue necrosis and sloughing may occur if vasopressor medications infiltrate the tissues. When possible, vasoactive medications should be given using central IV lines (Bauer et al., 2019). Furthermore, the need for the central IV access devices should be reviewed daily to reduce the risk of CLABSIs (Marschall, Mermel, Fakih, et al., 2014). The nurse must also monitor urine output, serum electrolytes, BUN, and serum creatinine levels to detect decreased renal function secondary to the effects of cardiogenic shock or its treatment.

Maintaining Intra-Aortic Balloon Counterpulsation

The nurse plays a critical role in caring for the patient receiving intra-aortic balloon counterpulsation. The nurse makes ongoing timing adjustments of the balloon pump to maximize its effectiveness by synchronizing it with the cardiac cycle. The patient is at risk for circulatory compromise to the leg on the side where the catheter for the balloon has been inserted; therefore, the nurse must check the neurovascular status of the lower extremities frequently.

Prioritizing orders in the care of sepsis
Fluid replacement must be instituted to correct tissue hypoperfusion that results from the incompetent vasculature and the inflammatory response. Reestablishing tissue perfusion through aggressive fluid resuscitation is key to the management of sepsis and septic shock (Rhodes et al., 2017; Singer et al., 2016). An initial fluid challenge, which includes an IV infusion of at least 30 mL/kg of crystalloids over 30 minutes, may be required to aggressively treat sepsis-induced tissue hypoperfusion. In addition to monitoring BP, patient mentation, respiratory rate, fluid responsiveness after PLR, urine output, and serum lactate levels are monitored to assess effectiveness of fluid resuscitation.
If the infecting organism is unknown, broad-spectrum antibiotic agents are started until culture and sensitivity reports are received (Levy & Townsend, 2019; Rhodes et al., 2017), at which time the antibiotic agents may be changed to agents that are more specific to the infecting organism and less toxic to the patient.
If fluid therapy alone does not effectively improve tissue perfusion, vasopressor agents, specifically norepinephrine or dopamine, may be initiated to achieve a MAP of 65 mm Hg or higher. Inotropic agents may also be given to provide pharmacologic support to the myocardium. Packed red blood cells may be prescribed to support oxygen delivery and transport to the tissues. Neuromuscular blockade agents and sedation agents may be required to reduce metabolic demands and provide comfort to the patient. Deep vein thrombosis (DVT) prophylaxis with low-dose unfractionated heparin or low-molecular-weight heparin, in combination with mechanical prophylaxis (e.g., sequential compression devices) should be initiated, as well as medications for stress ulcer prophylaxis (e.g., H2-blocking agents, proton pump inhibitors).
Aggressive nutritional supplementation should be initiated within 24 to 48 hours of ICU admission to address the hypermetabolic state present with septic shock (Reintam et al., 2017; Wang et al., 2019). Malnutrition further impairs the patient’s resistance to infection. Enteral feedings are preferred to the parenteral route because of the increased risk of iatrogenic infection associated with IV catheters; however, enteral feedings may not be possible if decreased perfusion to the GI tract reduces peristalsis and impairs absorption.

Prioritizing orders in the care of hypovolemic shock
Treatment of Underlying Cause (hemorrhage- stop bleeding, diarrhea/vomiting- meds to stop those)

Fluid and Blood Replacement: At least two large-gauge IV lines are inserted to establish access for fluid administration.

Fluids- Normal Saline, Lactated Ringers, Albumin, and plasma/RBC

In addition to administering fluids to restore intravascular volume, positioning the patient properly assists fluid redistribution. A modified Trendelenburg position, also known as passive leg raisingis recommended in hypovolemic shock.

Assessing septic shock
When caring for a patient with sepsis or septic shock, the nurse collaborates with other members of the health care team to identify the site and source of sepsis and the specific organisms involved. The nurse often obtains appropriate specimens for culture and sensitivity. Prescribed antibiotics are not given until these specimens are obtained. Hyperthermia (elevated body temperature) is common with sepsis and raises the patient’s metabolic rate and oxygen consumption. Efforts may be made to reduce the temperature by administering acetaminophen or applying a hypothermia blanket. During these therapies, the nurse monitors the patient closely for shivering, which increases oxygen consumption. Efforts to increase comfort are important if the patient experiences fever, chills, or shivering.
The nurse administers prescribed IV fluids and medications, including antibiotic agents and vasoactive medications, to restore vascular volume. Because of decreased perfusion, serum concentrations of antibiotic agents that are normally cleared by the kidneys and liver may increase and produce toxic effects. Therefore, the nurse monitors blood levels (serum levels of antibiotic agents, procalcitonin, CRP, BUN, creatinine, WBC count, hemoglobin, hematocrit, platelet levels, coagulation studies) and reports changes to the primary provider. As with other types of shock, the nurse monitors the patient’s hemodynamic status, fluid I&O, daily weight, and nutritional status. Close monitoring of serum albumin and prealbumin levels helps determine the patient’s protein requirements.

Frostbite Management
The goal of management is to restore normal body temperature. Constrictive clothing and jewelry that could impair circulation are removed. Wet clothing is removed as rapidly as possible. If the lower extremities are involved, the patient should not be allowed to ambulate.
Controlled yet rapid rewarming is instituted. Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. This treatment is repeated until circulation is effectively restored. Early rewarming appears to decrease the amount of ultimate tissue loss. During rewarming, an analgesic for pain is given as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.
Once rewarmed, the part is protected from further injury and is elevated to help control swelling. Sterile gauze or cotton is placed between affected fingers or toes to prevent maceration, and a bulky dressing is placed on the extremity

Hypothermia Active Rewarming
Active internal (core) rewarming methods are used for moderate to severe hypothermia (less than 28°C to 32.2°C [82.5°F to 90°F]) and include cardiopulmonary bypass, warm fluid administration, warmed humidified oxygen by ventilator, and warmed peritoneal lavage. Monitoring for ventricular fibrillation as the patient’s temperature increases from 31°C to 32°C (88°F to 90°F) is essential.

Hypothermia Passive Rewarming
Passive or active external rewarming is used for mild hypothermia (32.2°C to 35°C [90°F to 95°F]). Passive external rewarming uses over-the-bed heaters to the extremities and increases blood flow to the acidotic, anaerobic extremities. The cold blood from peripheral tissues has high lactic acid levels. As this blood returns to the core, it causes a significant drop in the core temperature (i.e., core temperature after drop) and can potentially cause cardiac dysrhythmias and electrolyte disturbances. Active external rewarming uses forced-air warming blankets. Care must be taken to prevent extremity burn from these devices, because the patient may not have effective sensation to feel the burn.

Decompression sickness
Decompression sickness, also known as “the bends,” occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. It occurs relatively infrequently in the United States, but its effects can be hazardous. Being aware of decompression sickness and assessing the patient properly ensures appropriate management and results in decreased morbidity.
Decompression sickness results from formation of nitrogen bubbles that occur with rapid changes in atmospheric pressure. They may occur in joint or muscle spaces, resulting in musculoskeletal pain, numbness, or hypesthesia. More significantly, nitrogen bubbles can become air emboli in the bloodstream and thereby produce stroke, paralysis, or death. Taking a rapid history about the events preceding the onset of symptoms is essential

Decompression sickness S/S
To identify decompression sickness, a detailed history is obtained from the patient or diving partner. Evidence of rapid ascent, loss of air in the tank, buddy breathing, recent alcohol intake or lack of sleep, or a flight within 24 hours after diving suggests possible decompression sickness. Some patients describe a perfect dive yet still have the signs and symptoms of decompression sickness, in which case they must receive treatment for the condition.
Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. Neurologic symptoms mimicking those of a stroke or spinal cord injury can indicate an air embolus. Cardiopulmonary arrest can also occur in severe cases and is usually fatal. Any neurologic symptoms should be rapidly assessed. All patients with decompression sickness need rapid transfer to a hyperbaric chamber

Decompression sickness management
A patent airway and adequate ventilation are established, as described previously, and 100% oxygen is given throughout treatment and transport. A chest x-ray is obtained to identify aspiration, and at least one IV line is started with lactated Ringer’s or normal saline solution. Research findings suggest that among patients requiring air transport (e.g., helicopter), oxygen saturations and symptoms improve when both oxygen and IV fluids are given. If air transport is required, the aircraft should remain at low altitude (i.e., below 300 m [approximately 1000 feet]) (Holleran, Wolfe, & Frakes, 2018).
The cardiopulmonary and neurologic systems are supported as needed. If an air embolus is suspected, the head of the bed should be lowered. If the patient’s wet clothing is still present, it is removed. The patient is kept warm. Transfer to the closest hyperbaric chamber for treatment is initiated. However, the patient who is awake and alert without central neurologic deficits may be able to travel by ground ambulance or by automobile, depending on the severity of symptoms. Throughout treatment, the patient is continually assessed, and changes are documented. If aspiration is suspected, antibiotic agents and other treatment may be prescribed

Family Focused Interventions
The family is kept informed about where the patient is, how he or she is doing, and the care that is being given. Encouraging family members to stay with the patient, when possible, also helps allay their anxieties. In many facilities, family presence during resuscitation is permitted to assist the family in coping through this difficult time. Many family members respond very well to this approach. One study found that families view emergency professionals favorably when a family member was resuscitated. They view their role as supportive and protective of the patient. Allowing family presence in the critical care areas of the hospital enhances the family role and builds trust in the caregivers. Posttraumatic stress disorder (PTSD) is less likely to occur if the family member is present during resuscitation. The presence of a family facilitator, who is trained to provide support to family members, is vital to the success of a family presence program. Additional interventions are based on the assessment of the stage of crisis that the family is experiencing.
Helping Family Members

Emergency surgery risk factor
Patients who hemorrhage are at risk for cardiac arrest caused by hypovolemia with secondary anoxia.

Caring for Emergency Personnel
Concerted efforts have been made to focus on the needs of the ED staff, especially after serious and stressful events (ENA, 2020a). Events can range from a local trauma case involving children; to treating someone known to the emergency worker, such as a colleague or family member; to a more complex natural disaster or mass casualty incident. It is important to remember that all staff members may not necessarily respond in the same way; an event that is stressful to one person may not be as stressful to another. Compassion fatigue may result from continuous exposure to suffering and injury, and energy is expended on a daily basis. Fatigue occurs when the affected staff members cannot replenish energy stores (Schmidt & Haglund, 2017). In addition, because stress is a daily occurrence in the ED, staff may not recognize the personal effect of any one event or the cumulative effect of day-to-day crisis interventions. ED leadership should be aware of staff coping patterns and support systems, patterns of interactions between staff members, staff members’ health problems, including addiction, and appropriately assist with identifying behaviors caused by workplace stress. The availability of nonjudgmental counseling is essential to promoting a healthy staff.

After serious events, critical incident stress management (CISM) is useful to critique individual and group performance and to facilitate healthy coping. Optimally, this consists of three steps: defusing, debriefing, and follow-up. Defusing occurs immediately after the critical incident. During this session, affected staff are encouraged to discuss their feelings about the incident, are reassured that negative reactions and feelings are normal but that these diminish over time, and are given contact information so that they may talk to someone if they have disturbing symptoms (e.g., sleeplessness, excessive worry). Debriefing typically occurs 1 to 10 days after the critical incident. Debriefing sessions follow a format similar to the initial defusing session; however, during these sessions, participating staff are encouraged to discuss their feelings about the incident and are again reassured that their negative reactions and feelings are normal and that their negative feelings will diminish over time. At the end of these sessions, participants should have a feeling of closure and be able to resume their professional roles at an emotional level commensurate to that prior to the critical incident. Some staff may require further professional follow-up, however. Follow-up may occur after the debriefing session is completed for those participants who have persistent negative symptoms and may consist of continued individual or group counseling and therapy (Schmidt & Haglund, 2017).

Care of patients with violent behaviors
A victim of trafficking may present to the ED with injury, accompanied by a significantly older boyfriend or travel partner. The victim may have a history of being a chronic runaway, or of homelessness, and of self-mutilation. Common behaviors exhibited by these patients may include cowering or deferring to the person accompanying them, who may appear controlling, and appearing frightened or agitated. The patient may have a special mark/tattoo present, poor dentition, and multiple injuries in various stages of healing. Common physical complaints include injuries, poor healing or poorly healed old injuries, abdominal pain, dizziness, headaches, rashes, or sores. Patients may demonstrate addiction, panic attacks, impulse control, hostility, and suicidal ideation (Roney & Villano, 2020).

The ED nurse may be well positioned to offer an opportunity for the patient to speak, alone without an accompanying companion, who could be a perpetrator of abuse. Targeted, appropriate questions may include asking patients if they are in control of their own money; whether or not they are able to come and go as they please; and who is the person or persons accompanying them (ENA, 2020a). Patients may decline assistance.