Sutures, staples, steri-strips<\/li>\n<\/ul>\n\n\n\nComplications 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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Hypothermia Interventions
Management consists of removal of wet clothing, continuous monitoring, rewarming, and supportive care.<\/p>\n\n\n\n
Monitoring ABCs
Core body temp is monitored through esophageal, bladder, or rectal<\/p>\n\n\n\n
Rewarming methods include active internal (core) rewarming and passive (spontaneous) or active external rewarming<\/p>\n\n\n\n
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\u00b0C [88\u00b0F])
Defibrillation of ventricular fibrillation. A patient whose temperature is less than 32\u00b0C [90\u00b0F] experiences spontaneous ventricular fibrillation if moved or touched.<\/p>\n\n\n\n
Defibrillation is ineffective in patients with temperatures lower than 31\u00b0C (88\u00b0F); therefore, the patient must be rewarmed first.<\/p>\n\n\n\n
Mechanical ventilation with positive end-expiratory pressure (PEEP) and heated humidified oxygen to maintain tissue oxygenation<\/p>\n\n\n\n
Administration of warmed IV fluids to correct hypotension and to maintain urine output and core rewarming, as described previously<\/p>\n\n\n\n
Administration of sodium bicarbonate to correct metabolic acidosis if necessary<\/p>\n\n\n\n
Administration of antiarrhythmic medications<\/p>\n\n\n\n
Insertion of an indwelling urinary catheter to monitor urinary output and kidney function<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Preventing Cardiogenic Shock<\/p>\n\n\n\n
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\u2019s 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.<\/p>\n\n\n\n
Monitoring Hemodynamic Status<\/p>\n\n\n\n
A major role of the nurse is monitoring the patient\u2019s 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.<\/p>\n\n\n\n
Administering Medications and Intravenous Fluids<\/p>\n\n\n\n
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\u2019s response to treatment.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Maintaining Intra-Aortic Balloon Counterpulsation<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Prioritizing orders in the care of hypovolemic shock
Treatment of Underlying Cause (hemorrhage- stop bleeding, diarrhea\/vomiting- meds to stop those)<\/p>\n\n\n\n
Fluid and Blood Replacement: At least two large-gauge IV lines are inserted to establish access for fluid administration.<\/p>\n\n\n\n
Fluids- Normal Saline, Lactated Ringers, Albumin, and plasma\/RBC<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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\u00b0C to 40\u00b0C (98.6\u00b0F to 104\u00b0F) 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<\/p>\n\n\n\n
Hypothermia Active Rewarming
Active internal (core) rewarming methods are used for moderate to severe hypothermia (less than 28\u00b0C to 32.2\u00b0C [82.5\u00b0F to 90\u00b0F]) 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\u00b0C to 32\u00b0C (88\u00b0F to 90\u00b0F) is essential.<\/p>\n\n\n\n
Hypothermia Passive Rewarming
Passive or active external rewarming is used for mild hypothermia (32.2\u00b0C to 35\u00b0C [90\u00b0F to 95\u00b0F]). 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.<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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<\/p>\n\n\n\n
Emergency surgery risk factor
Patients who hemorrhage are at risk for cardiac arrest caused by hypovolemia with secondary anoxia.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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).<\/p>\n\n\n\n
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).<\/p>\n\n\n\n
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.<\/p>\n","protected":false},"excerpt":{"rendered":"
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 withQuestions and Verified Answers| 100%Correct- HerzingQ: Triage patients in the EDAnswer:Use ESI (emergency severity index) toolResponsibilities of triage nurse:Assess, reassess, […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-131285","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/131285","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=131285"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/131285\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=131285"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=131285"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=131285"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}