Allen's test

To assure adequate circulation to the hand before proceeding with the arterial blood gas
collection.
The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it
is near the surface, easy to palpate and stabilize, and has good collateral supply from the ulnar
artery. The patency of the ulnar artery must be confirmed.
The modified Allen's test includes the following steps:
• Instruct the client to make a tight fist (if possible)
• Occlude the radial and ulnar arteries using firm pressure
• Instruct the client to open the fist; the palm will be white if both arteries are sufficiently
occluded
• Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as
circulation is restored to the hand, indicating patency of the ulnar artery (positive Allen's
test)
When caring for a client with a radial, brachial, or femoral arterial line in place, the nurse must be
able to assess for complications. These include hemorrhage, infection, thrombus formation, and
circulatory and neurovascular impairment.

To measure pressures accurately using continual arterial and/or pulmonary artery pressure
monitoring, the zeroing stopcock of the transducer system must be placed at the phlebostatic
axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at
the midway point of the AP diameter (½ AP) of the chest wall. If the transducer is placed too
low, the reading will be falsely high; if placed too high, the reading will be falsely low. This
concept is similar to the positioning of the arm in relation to the level of the heart when
measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure-
monitoring device. The upper arm should be at the level of the phlebostatic axis.

Implantable cardioverter defibrillator (ICD)

The client with an ICD that is firing is receiving electrical shocks from the internal defibrillator to
interrupt the dysrhythmia. It is still imperative that the client receive chest compressions in the
form of cardiopulmonary resuscitation (CPR) to provide circulation of blood to the vital
organs. The nurse should implement the pulseless arrest algorithm, allowing 30-60 seconds for
the ICD to complete its therapy cycle before applying external defibrillation pads/paddles.

Suspected cervical spine injury

The priorities for a client with a suspected cervical spine injury are maintaining a patent airway
and spinal immobilization. Interventions include application of a rigid hard collar, placing the
client on a firm surface, logrolling the client during movement and transfers, and continued
assessment of need for an advanced airway. Further stabilization is achieved by taping down the
client's head and using straps to immobilize the arms, especially if the client is not cooperating.

Mechanical ventilation
Clients are at risk for a variety of ventilator-associated complications (eg, aspiration,
pneumonia). When caring for a client receiving mechanical ventilation, the nurse should:
• Monitor respiratory status (eg, lung sounds, breathing pattern), airway patency, and
ventilator functionality (eg, settings, alarm parameters).
• Maintain the head of the bed at 30-45 degrees to reduce aspiration risk
• Use the minimum amount of sedation necessary for client comfort (eg, compliant with
ventilator, opens eyes to voice). Continuous IV sedation should be paused daily for
evaluation of spontaneous respiratory effort and appropriateness for weaning off the
ventilator
 • Perform oral care with chlorhexidine oral solution every 2 hours, or per facility
policy Perform tracheal suctioning as needed.
• Monitor correct endotracheal tube placement by noting insertion depth.
• Place emergency equipment at bedside (eg, manual resuscitation bag)
A drop in oxygen saturation signifies a problem with ventilation. When an artificial airway is
present, the nurse should assess the client to determine the cause of hypoventilation. Auscultating
lung sounds is the first step and quickest intervention to confirm proper tube placement. It is not
uncommon for the tube to become displaced in the hypopharynx, which would not allow proper
ventilation.
Another important complication is pneumothorax, which can cause hypotension and a drop in
oxygen saturation. Lung auscultation would help diagnose this as well.

Malignant hyperthermia (MH)

a rare and life-threatening condition precipitated by certain medications used for anesthesia,
including inhaled anesthetics (eg, desflurane, isoflurane, halothane) and succinylcholine (a
paralytic used adjunctively for intubation and general anesthesia). Skeletal muscles become
unable to control calcium levels, leading to a hypermetabolic state manifested by contracture and
increased temperature. Early signs of MH include tachypnea, tachycardia, and a rigid jaw or
generalized rigidity. As the condition progresses, the client develops a high fever. Muscle tissue
is broken down, leading to hyperkalemia, cardiac dysrhythmias, and myoglobinuria.
MH requires emergent treatment with IV dantrolene to reverse the process by slowing
metabolism. Succinylcholine should be discontinued. Other interventions include applying
cooling blankets to reduce temperature and treating high potassium levels.
triggered by certain drugs used to induce general anesthesia in susceptible clients. T
signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (eg,
jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a
suspicion of MH. The nurse monitors the temperature as it can rise 1 degree Celsius every 5
minutes and can exceed 105 F (40.6 C).
The nurse would notify the health care provider, indicating the need for immediate treatment
(eg, dantrolene, cooling blanket, fluid resuscitation)

Gastric lavage (GL)

is performed through an orogastric tube to remove ingested toxins and irrigate the stomach. GL
is rarely performed as it is associated with a high risk of complications (eg, aspiration, esophageal
or gastric perforation, dysrhythmias). GL is only indicated if the overdose is potentially lethal
and if GL can be initiated within one hour of the overdose. Activated charcoal administration is
the standard treatment for overdose, but it is ineffective for some drugs (eg, lithium, iron,
alcohol). Activated charcoal is an important treatment in early acetylsalicylic acid (ASA)
toxicity; it is recommended for gastrointestinal decontamination in clients with clinical signs of
ASA poisoning (disorientation, vomiting, hyperpnea, diaphoresis, restlessness) as well as in those
who are asymptomatic. IV sodium bicarbonate is an appropriate treatment for aspirin toxicity
after the administration of activated charcoal. It is given to make the blood and urine more
alkaline, therefore promoting urinary excretion of salicylate.
Similar to syrup of ipecac, gastric lavage is associated with risk of aspiration. In addition, there is
no convincing evidence that it decreases morbidity. It is not routinely recommended but may be
performed for the ingestion of a massive or life-threatening amount of drug. If necessary, it
should be administered within 1 hour of ingestion and requires a protected airway and possible
sedation.
Intubation and suction supplies should always be available at the bedside during GL in case the
client develops aspiration or respiratory distress
performed through a large-bore (36 to 42 French) orogastric tube so that a large volume of water
or saline can be instilled in and out of the tube.
Clients should be placed on their side or with the head of bed elevated to minimize aspiration
risk.
should be initiated within one hour of overdose ingestion to be effective. The client's stomach
should be decompressed first, but lavage should be initiated as soon as possible afterwards.

Hypothermia
occurs when the core temperature is below 95 F (35 C) and the body is unable to compensate for
heat loss. As the core temperature decreases, the cold myocardium becomes extremely irritable
and prone to dysrhythmias. The client should be handled gently as spontaneous ventricular
fibrillation could develop when moved or touched. Therefore, placing the client on a cardiac
monitor is a high priority; the nurse should anticipate defibrillation in these clients.

Frostbite
involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes
peripheral vasoconstriction, reduced blood flow, vascular stasis, and cell damage. Superficial
frostbite can manifest as mottled, blue, or waxy yellow skin. Deeper frostbite may cause skin to
appear white and hard and unable to sense touch. This can eventually progress to gangrene.
Treatment of frostbite should include the following:
• Remove clothing and jewelry to prevent constriction.
• Do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged
• Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a
whirlpool. Higher temperatures do not significantly decrease rewarming time but can
intensify pain
• Avoid heavy blankets or clothing to prevent tissue sloughing.
• Provide analgesia as the rewarming procedure is extremely painful
• As thawing occurs, the injured area will become edematous and may blister. Elevate the
injured area after rewarming to reduce edema
• Keep wounds open immediately after a water bath or whirlpool treatment and allow them
to dry before applying loose, nonadherent, sterile dressings
• Monitor for signs of compartment syndrome.

Arterial blood gases (ABGs)

It is common to measure ABGs after a ventilator change to assess how well the client has
tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning
within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's
condition dictates otherwise, the nurse should avoid suctioning as it will deplete the
client's oxygen level and cause inaccurate test results.

Positive pressure ventilation (PPV)

delivers positive pressure to the lungs using a mechanical ventilator (MV), either invasively
through a tracheostomy or endotracheal tube or noninvasively through a nasal mask/facemask,
nasal prongs, or a mouthpiece. The most common type used in the acute care setting for clients
with acute respiratory failure is the volume cycled positive pressure MV, which delivers a preset
volume and concentration of oxygen (eg, 21%-100%) with varying pressure.
Positive pressure applied to the lungs compresses the thoracic vessels and increases intrathoracic
pressure during inspiration. This leads to reduced venous return, ventricular preload, and cardiac
output, which results in hypotension. The hypotensive effect of PPV is even greater in the
presence of hypovolemia (eg, hemorrhage, hypovolemic shock) and decreased venous tone (eg,
septic shock, neurogenic shock).
Fluid and/or sodium retention usually occurs about 48-72 hours after initiation of PPV

Guillain-Barré syndrome (GBS)

an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle
paralysis and absence of reflexes. Lower-extremity weakness progresses over hours to days to
involve the thorax, arms, and cranial nerves (CNs). Neuromuscular respiratory failure is the most
life-threatening complication. The rate and depth of the respirations should be monitored
Measurement of serial bedside forced vital capacity (spirometry) is the gold standard for
assessing early ventilation failure.
Absence of knee reflexes is expected early in the course of GBS due to the ascending nature of
the disease. Absence of gag reflex indicates GBS progression.
orthostatic hypotension, paralytic ileus, urinary retention, and diaphoresis. These complications
need to be assessed but are not a priority.
ascending nature of GBS

Cerebrospinal fluid (CSF) rhinorrhea

can confirm that a skull fracture has occurred and transversed the dura. If the drainage is
clear, dextrose testing can determine if it is CSF. However, the presence of blood would make
this test unreliable as blood also contains glucose. In this case, the halo/ring test should be
performed by adding a few drops of the blood-tinged fluid to gauze and assessing for the
characteristic pattern of coagulated blood surrounded by CSF.
Identification of this pattern is very important as CSF leakage places the client at risk
for infection. The client's nose should not be packed. No nasogastric or oral gastric tube should
be inserted blindly when a basilar skull fracture is suspected as there is a risk of penetrating the
skull through the fracture site and having the tube ascend into the brain. These tubes are placed
under fluoroscopic guidance in clients with such fractures.

Ventilator-associated pneumonia (VAP)

classified as a diagnosis of pneumonia more than 48 hours post-endotracheal intubation, is a key
area of preventable morbidity and mortality in the hospitalized client. Assessment of suspected
pneumonia would denote fever, elevated white blood cell count, purulent or odorous sputum,
crackles on auscultation, and pulmonary opacities on x-ray.
Prevention of pneumonia in a client on ventilation focuses on minimizing time spent on
ventilation, reducing bacterial colonization with sterile equipment, regular oral hygiene, and
aspiration prevention protocols.
Proton pump inhibitors (eg, omeprazole) and histamine-2 antagonists (eg, ranitidine) are
commonly prescribed during inpatient client care, but the natural acidity of stomach acid is
important in killing bacteria. Prophylaxis should be prescribed only to clients at clear risk for
developing stress ulcers.
Specific steps include sealing the endotracheal tube cuffing with ≥20 cm H 2O (15 mm Hg),
routine oral hygiene with chlorhexidine, elevating the head of the bed, minimizing sedation, and
extubating as soon as possible.

Hemodynamic Monitoring
Invasive arterial line and manual cuff readings measure BP via 2 different methods. The arterial
line measures flow of the blood past a catheter, and the manual cuff measures pressure based on
compression of the artery. Because of the differences, the 2 pressures may not match. The
arterial line can be highly useful to the clinician as it gives a continuous measurement of accurate
BP. The manual cuff will give a reading of the pressure only at the moment the pressure is
measured. The following steps should be instituted to ensure accuracy of invasive pressure
readings:
 1. Position the client supine, flat, prone, or with the head of the bed <45 degrees
2. Confirm zero reference stopcock (port of the stopcock nearest to the transducer) to be at
the level of the phlebostatic axis (4th intercostal space, midaxillary line), which
approximates the level of the atria of the heart
3. Zero the system after initial setup, with disconnection of the transducer or when accuracy
of the measurements is questioned
4. Perform a dynamic response test (square wave test) every 8-12 hours, when the system is
opened to air or when accuracy of measurements is questioned
5. Measure pressures at the end of expiration

SIRS is a generalized inflammatory response to an infectious or noninfectious insult to the

body. It is often difficult to distinguish from early sepsis. When SIRS is suspected, a source for
sepsis should be sought.
Diagnostic criteria for SIRS include 2 or more of the following manifestations:
• Hyperthermia (temperature >100.4 F [38 C]) or hypothermia (temperature <96.8 F [36
C])
• Heart rate >90/min
• Respiratory rate >20/min or alkalosis (PaCO 2 <32 mm Hg [4.3 kPa])
• Leukocytosis (WBC count >12,000/mm3 [12.0 x 109/L] or 10% immature neutrophils
[bands])
Sepsis is a systemic inflammatory response (ie, increased heart rate, respirations, temperature,
and decreased systolic blood pressure) to a documented or suspected infection and is present in
this client. Sepsis is a potentially life-threatening condition. Physiologic changes related to the
aging process, including decreased immune function and inflammatory response
(immunosenescence) and altered febrile response to pyrogens, increase the risk for
sepsis. Although evidence indicates that early recognition of sepsis is critical to survival, atypical
presentation associated with immunosenescence and absence of fever can delay diagnosis and
treatment. Hypothermia in the presence of altered mental status, tachycardia, and borderline low
blood pressure should alert the nurse to the possibility of early sepsis. Transfer to the intensive
care unit for evaluation, continual monitoring, and evidenced-based treatment measures (ie, sepsis
bundles) should be anticipated. Pressure injury could be the likely source of bacteremia in this
client.
Sepsis-induced hypotension despite adequate fluid resuscitation (30 mL/kg) is defined
as "septic shock."
MODS is the failure of 2 or more body organs (eg, acute kidney injury, acute respiratory distress
syndrome). Septic shock can progress to multiorgan dysfunction (ie, severe end of sepsis and
septic shock).

Defibrillation is indicated in clients with ventricular fibrillation (Vfib) and pulseless ventricular
tachycardia. Cardiopulmonary resuscitation (CPR) should be initiated and compressions
continued until the shock is ready to be delivered. Certain pulseless rhythms (asystole and
pulseless electrical activity) do not need defibrillation.
Steps to perform defibrillation are as follows:
1. Turn on the defibrillator
2. Place defibrillator pads on the client's chest
3. Charge defibrillator. Chest compressions should continue until defibrillator has charged
and is ready to deliver the shock.
4. Before delivering the shock, ensure that the area is "all clear." Confirm that no personnel
are touching the client, bed, or any equipment attached to the client
5. Deliver the shock
6. Immediately resume chest compressions
 Synchronized cardioversion delivers a shock on the R wave of the QRS complex
Rhythms that are ideal for synchronized cardioversion are supraventricular tachycardia,
ventricular tachycardia with a pulse, and atrial fibrillation with rapid ventricular response. If the
defibrillator is not synchronized with the R wave in a client with a pulse, the shock may be
delivered on the T wave and can cause a lethal arrhythmia (eg, Vfib).

Hypovolemic (hemorrhagic) shock

may occur after abdominal trauma or surgery as mesenteric edema resolves and previously
compressed sites of bleeding reopen.
The shock continuum is staged in severity from initial (I) to irreversible (IV). During the initial
stage, there is inadequate oxygen to supply the demand at the cellular level and anaerobic
metabolism develops. At this point, there may be no recognizable signs or symptoms. As shock
progresses to the compensatory stage, sympathetic compensatory mechanisms are activated to
maintain homeostasis (eg, oxygenation, cardiac output).
Cold, clammy skin indicates failing compensatory mechanisms (ie, progressive stage),
and immediate intervention is necessary to prevent irreversible shock and death

Nursing priorities when implementing a chemical contamination emergency response plan

include the following:
1. Restricting other clients, staff, and bystanders from the victims' vicinity to protect non-
affected individuals and the health care facility from the contaminant
2. Donning personal protective equipment to protect the nurse when providing care
3. Decontaminating the clients outside the facility before initiating treatment. If the
chemical is not removed, it will continue to cause respiratory distress; contaminated
clothing is left outside the facility to reduce the risk of contaminating staff and other
clients
4. Assessing and providing treatment of symptoms. Initial treatment is for the symptoms
(eg, wheezing), regardless of the specific cause

Hypovolemic shock
the most common type of shock, occurs when blood volume decreases through hemorrhage or
movement of fluid from the intravascular compartment into the interstitial space (third-spacing).
Treatment involves preventing additional fluid loss, restoring volume through IV fluids, and
improving hemodynamic stability through vasoactive medications (eg, norepinephrine,
dopamine). Norepinephrine causes vasoconstriction and improves heart contractility/output, but
the effects end quickly. It should be tapered slowly and cautiously to avoid the progression or
relapse of shock.
Narrowing pulse pressure (the difference between systolic and diastolic) is a sign of hypovolemic
shock
Hypovolemic shock occurs when blood volume decreases via hemorrhage or third-spacing.
Stopping the source of blood loss, increasing blood volume through IV fluids, and improving
blood pressure with vasoactive medications are the first steps in treating this condition. Abruptly
discontinuing vasoactive medications can cause hemodynamic instability; these medications
should always be tapered slowly.
Normal saline is the fluid of choice for rapid correction of hypotension in most situations,
including hypovolemic and septic shock. It can be administered in large quantities rather rapidly
and is inexpensive.

Near-drowning
occurs when a client is under water and unable to breathe for an extended period. In a matter of
seconds, major body organs begin to shut down from lack of oxygen and permanent damage
results. Decerebrate posturing (arms and legs straight out, toes pointed down, head/neck arched
back) is a sign of severe brain damage. During assessment, the nurse would observe arms and
legs straight out, toes pointed down, and the head/neck arched back. These assessment findings
indicate that severe injury has occurred.
Hypothermia is generally seen in near-drowning victims. One of the first goals of treatment is to
warm the client. This is done using warmed IV fluids, blankets, and air. Sustained hypothermia
will eventually lead to organ failure, making this an urgent finding but not initially life-
threatening.
A weak and thready pulse is generally detected in near-drowning victims due to
hypothermia. Once the client is properly warmed, the pulse generally returns to
normal. Sometimes the client is so cold that a pulse cannot be detected; this is why a client is not
dead until warm and dead. Such clients may require prolonged resuscitation.
When wheezing is heard on auscultation after a near-drowning, the first observation would be
that the client is still moving air and providing oxygen to the body. The wheezing may indicate
that the client has bronchospasm. If the client has aspirated fluid, crackles would be heard. Most
such clients will develop acute respiratory distress syndrome.
The initial management of a near-drowning victim focuses on airway management due to
potential aspiration (leading to acute respiratory distress syndrome), pulmonary edema, or
bronchospasm (leading to airway obstruction). Hypoxia is managed and prevented by ensuring a
patent airway via intubation and mechanical ventilation as necessary
Careful handling of the hypothermic client is important because as the core temperature
decreases, the cold myocardium becomes extremely irritable. Frequent turning could cause
spontaneous ventricular fibrillation and should not be performed during the acute stage of
hypothermia. Continuous cardiac monitoring should be initiated
There are passive, active external, and active internal rewarming methods. Passive rewarming
methods include removing the client's wet clothing, providing dry clothing, and applying warm
blankets. Active external rewarming involves using heating devices or a warm water
immersion. Active internal rewarming is used for moderate to severe hypothermia and involves
administering warmed IV fluids and warm humidified oxygen

Therapeutic hypothermia
Neurologic injury is the most common cause of mortality in clients who have had cardiac arrest,
particularly ventricular fibrillation or pulseless ventricular tachycardia.
Inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for
24 hours has been shown to decrease mortality rates and improve neurologic outcomes. It is
indicated in all clients who are comatose or do not follow commands after resuscitation.
The client is cooled to 89.6-93.2 F (32-34 C) for 24 hours before rewarming. Cooling is
accomplished by cooling blankets; ice placed in the groin, axillae, and sides of the neck; and cold
IV fluids. The nurse must closely assess the cardiac monitor (bradycardia is common), core body
temperature, blood pressure (mean arterial pressure to be kept >80 mm Hg), and skin for thermal
injury. The nurse must also apply neuroprotective strategies such as keeping the head of the bed
elevated to 30 degrees. After 24 hours, the client is slowly rewarmed.
Clients are generally kept NPO during therapeutic hypothermia and rewarming.

Tension pneumothorax
This is a life-threatening emergency
causes marked compression and shifting of mediastinal structures (tracheal deviation), including
the heart and great vessels, resulting in reduced cardiac output and hypotension. This is a life-
threatening emergency. The client should have emergency large-bore needle decompression,
followed by chest tube placement, to relieve the compression on the mediastinal structures.
Dopamine (Intropin)
a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status in
clients with shock and heart failure. It enhances cardiac output by increasing myocardial
contractility, increasing heart rate, and elevating blood pressure through vasoconstriction. Renal
perfusion is also improved, resulting in increased urine output.
The lowest effective dose of dopamine should be used as dopamine administration leads to an
increased cardiac workload. Significant adverse effects include tachycardia, dysrhythmias,
and myocardial ischemia.
increases heart rate, blood pressure, cardiac output, and urine output

exacerbation of COPD
characterized by the acute worsening of a client's baseline symptoms (eg, dyspnea, cough, sputum
color and production). NIPPV is often prescribed short-term to support gas exchange in clients
who have moderate to severe COPD exacerbations and acidosis (pH <7.3)
or hypercapnia (PaCO2 >45 mm Hg). NIPPV can prevent the need for tracheal intubation and is
administered until the underlying cause of the ventilatory failure is reversed with pharmacologic
therapy (eg, corticosteroids, bronchodilators, antibiotics).
BIPAP involves the use of a mechanical device and facemask in a conscious client who is
breathing spontaneously. BIPAP delivers oxygen to the lungs and then removes carbon dioxide
(CO2). CO2 retention causes mental status changes. If the client becomes drowsy or confused, it
is likely that more CO2 is being retained than what BIPAP can remove; this should be reported to
the HCP. Arterial blood gas evaluation should be obtained to determine CO 2 level and BIPAP
effectiveness.
In a client with COPD exacerbation, it is most important for the nurse to monitor mental status
frequently and report changes such as restlessness, decreased level of consciousness, somnolence,
difficult arousal, and confusion to the HCP. These signs may indicate increased CO2 retention
and worsening hypercapnia, which would necessitate an immediate change in therapy.

Recently extubated
clients are at high risk for aspiration, airway obstruction (laryngeal edema and/or spasm), and
respiratory distress. To prevent complications, clients are placed in high Fowler position to
maximize lung expansion and prevent aspiration of secretions Warmed, humidified oxygen is
administered immediately after extubation to provide high concentrations of supplemental oxygen
without drying out the mucosa. Oral care is provided to decrease bacteria and contaminants as
well as promote comfort. Clients are instructed to frequently cough, deep breathe, and use
an incentive spirometer to expand alveoli and prevent atelectasis.
Clients are kept NPO after extubation to prevent aspiration. They may have either a bedside
swallow screen or a more formal swallow evaluation by a speech therapist prior to swallowing
any food, drink, or medication.

Nursing interventions to control ICP include:

• Elevating the head of the bed to 30 degrees with the head/neck in a neutral position to
reduce venous congestion
• Administering stool softeners to reduce the risk of straining (eg, Valsalva maneuver)
• Managing pain well while monitoring sedation
• Managing fever (eg, cool sponges, ice, antipyretics) while preventing shivering
• Maintaining a calm environment with minimal noise (eg, alarms, television, hall noise)
• Ensuring adequate oxygenation
• Hyperventilating and preoxygenating the client before suctioning; reducing CO2 (a potent
cerebral vasodilator) by hyperventilation induces vasoconstriction and reduces
 • Stimulation increases oxygen metabolism within the brain, increasing the risk for
irreversible brain damage in increased ICP. Limit performing interventions unless
absolutely necessary and avoid performing interventions in clusters.
Suction a maximum of 10 seconds and only as necessary to remove
secretions. Prolonged suctioning increases ICP.

Rapid response team

Recommended criteria to consider:
• Any provider worried about the client's condition OR
• An acute change in any of the following:
o Heart rate <40 or >130/min
o Systolic blood pressure <90 mm Hg
o Respiratory rate <8 or >28/min
o Oxygen saturation <90 despite oxygen
o Urine output <50 mL/4 hr
o Level of consciousness

Positive end-expiratory pressure (PEEP) applies a given pressure at the end of expiration
during mechanical ventilation. It counteracts small airway collapse and keeps alveoli open so
that they can participate in gas exchange. PEEP is usually kept at 5 cm H2O (3.7 mm
Hg). However, a higher level of PEEP is an effective treatment strategy for acute respiratory
distress syndrome (ARDS), a type of progressive respiratory failure that causes damage to the
type II surfactant-producing pneumocytes that then leads to atelectasis, noncompliant lungs, poor
gas exchange, and refractory hypoxemia.
High levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause overdistension and rupture of
the alveoli, resulting in barotrauma to the lung. Air from ruptured alveoli can escape into the
pulmonary interstitial space or pleural space, resulting in a pneumothorax and/or subcutaneous
emphysema.

Neurogenic shock, a distributive shock.

Vascular dilation with decreased venous return to the heart is present due to loss of innervation
from the spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin
from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries (T6
or higher).
Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the
kidneys. Administration of fluids is a priority to ensure adequate kidney and other organ
perfusion.

ventricular tachycardia (VT)

can be pulseless or have a pulse. Treatment is based on this important initial assessment. VT
with a pulse should be further assessed for clinical stability or instability. Signs of instability
include hypotension, altered mental status, signs of shock, chest pain, and acute heart failure.
The unstable client in VT with a pulse is treated with synchronized
cardioversion. The stable client in VT with a pulse is treated with antiarrhythmic
medications (eg, amiodarone, procainamide, sotalol).

Third-spacing
of fluids can occur 24-72 hours after extensive abdominal surgery as a result of increased
capillary permeability due to tissue trauma. It occurs when too much fluid moves from the
intravascular into the interstitial or third space, a place between cells where fluid does not
normally collect (ie, injured site, peritoneal cavity). This fluid serves no physiologic purpose,
cannot be measured, and leads to decreased circulating volume (hypovolemia) and cardiac output.
The priority intervention is to assess vital signs as the manifestations associated with third-
spacing include weight gain, decreased urinary output, and signs of hypovolemia, such
as tachycardia and hypotension. If third-spacing is not recognized and corrected early on,
postoperative hypotension can lead to decreased renal perfusion, prerenal failure, and
hypovolemic shock
tachycardia and hypotension, which are classic signs of hypovolemia.

The priority action after placing a subclavian central venous catheter is to check the results of
the chest x-ray to ensure that the catheter tip is placed correctly in the superior vena cava. Obtain
verification before using the catheter as perforation of the visceral pleura can occur during
insertion and lead to an iatrogenic pneumothorax or hemothorax. Although these complications
are rare, due to the use of ultrasound to guide insertion, if present, the TPN would infuse into the
pleural space.
Incorrect placement of a subclavian central venous catheter can result in an iatrogenic
pneumothorax or hemothorax. The priority is to check the results of the chest x-ray to verify that
the catheter tip has been placed correctly in the superior vena cava. Other appropriate actions
include attaching a filter to the IV tubing, monitoring baseline and fingerstick BG levels every 6
hours, and programming the electronic infusion device to ensure an accurate and consistent
hourly infusion rate.
monitor the baseline blood glucose (BG) level and fingerstick BG every 6 hours while the client
is receiving TPN; it should be maintained in the range of 140-180 mg/dL (7.8-10.0 mmol/L) for a
hospitalized adult client.

cardiopulmonary resuscitation (CPR)

For high-quality adult cardiopulmonary resuscitation, compressions should be in the center of the
chest; at a rate of 100-120/min; and at least 2 in (5 cm) but no more than 2.4 in (6 cm) deep for
adequate perfusion without unnecessary client injury. Compression interruption should be
minimized (eg, 30 compressions to 2 rescue breaths).
The sequence of basic life support includes assessing responsiveness by tapping or gently shaking
the client, activating the emergency response system (eg, calling a code), simultaneously
assessing pulse and breathing for no more than 10 seconds, initiating chest compressions if no
pulse is felt, and notifying the health care provider.
Two important modifications for cardiopulmonary resuscitation of a pregnant client include
performing chest compressions slightly higher on the sternum and displacing the uterus to the
client's left side.

** Norepinephrine (Levophed) is a vasopressor used to increase stroke volume, cardiac output,

and MAP. Titrating a norepinephrine infusion upward to maintain the MAP within normal limits
(>65 mm Hg) is an appropriate nursing action for a client in anaphylactic shock.

**During mass casualty events, the goal is the greatest good for the greatest number of
people. Priority is given to clients with life-threatening injuries who have good prognoses after
minimal intervention.

** A low pressure alarm for an arterial line can indicate the presence of hypotension or
disconnected tubing. Hemorrhage can rapidly occur with a disconnected arterial catheter
line. The nurse should check the client for the presence of hypotension and its causes before
troubleshooting the system.
** Indications of a need for IV isotonic fluids include capillary refill more than 3 seconds and
mottling, prehydration before an epidural anesthesia, and inadequate urine output and tachycardia
due to hyperemesis gravidarum.

After trauma to a client (eg, fall), the nurse performs an emergency or trauma assessment that
includes a primary and secondary survey (assessment). The primary assessment determines the
status of the airway, breathing, and circulation (ABCs). Next, the nurse evaluates disability
(D) of neurological function using the Glasgow Coma Scale (GCS).
The GCS measures the client's level of consciousness by assessing the best eye-opening response,
best verbal response, and best motor response. The lower the GCS score, the higher the risk for
the client to develop complications (eg, loss of airway patency, increased intracranial pressure).

To perform wound irrigation:

• Administer the analgesic 30-60 minutes before the procedure to allow medication to
reach therapeutic effect.
• Don a gown and mask with face shield to protect from splashing fluid and sterile gloves
to maintain surgical asepsis and prevent infection.
• Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution.
• Attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm)
above the area.
• Use continuous pressure to flush the wound, repeating until drainage is clear.
• Dry the surrounding wound area to prevent skin breakdown and irritation.
Immunization history is reviewed to determine tetanus vaccination status. Typically, a tetanus
vaccination is administered if the client has not had one within the last 5-10 years, depending on
the contamination level of the wound.

The EpiPen is designed to be administered through clothing with a swing and firm push against
the mid-outer thigh until the injector clicks. The position should be held for 10 seconds to allow
the entire contents to be injected. The site should be massaged for an additional 10 seconds.
Timing is essential in the delivery of epinephrine during an anaphylactic reaction. The nurse
should administer the medication immediately on the playground without removing the child's
clothing. Any delays can cause client deterioration and make maintenance of a patent airway
difficult. IV epinephrine is not administered outside the hospital setting. It requires cardiac
monitoring and is indicated in clients with profound hypotension (shock) or those who do not
respond to intramuscular epinephrine and fluid resuscitation.

Methadone
Early signs of toxicity include nausea/vomiting and lethargy. A client who falls asleep with
stimulation (is obtunded) requires additional observation/monitoring. Sedation precedes
respiratory depression, a life-threatening complication of severe toxicity. A reading of 90% is low
and indicates inadequate depth or rate of respiration with possible respiratory depression. Itching
sensation (pruritus) is an expected finding.
The principle of mass casualty incident (disaster) triage is the greatest good for the
greatest number of casualties. Clients with alteration in their airway, breathing, and
circulation who are likely to survive with timely interventions are given first priority.
Clients with stridor or pneumothorax are a priority. Full-thickness/3rd-degree burns over
the majority of the body indicate a poor prognosis.

external beam radiation therapy

Key measures of skin care that clients receiving teletherapy should take include:
Protect the skin from infection by not rubbing, scratching, or scrubbing
• Wear soft, loose-fitting clothing
• Use soft, cotton bed sheets and towels
• Pat skin dry after bathing
• Avoid applying bandages or tape to the treatment area
Cleanse the skin daily by taking a lukewarm shower
• Use mild soap without fragrance or deodorant
• Do not wash off any radiation ink markings
Use only creams or lotions approved by the health care provider (HCP)
• Avoid over-the-counter creams, oils, ointments, or powders unless specifically
recommended by the HCP as they can worsen any irritation
Shield the skin from the effects of the sun during and after treatment
• Avoid tanning beds and sunbathing
• Wear a broad-brimmed hat, long sleeves, and long pants when outside
• Use a sunscreen that is SPF 30 or higher
Avoid extremes in skin temperature
• Avoid heating pads and ice packs
• Maintain a cool, humid environment for comfort
The rule of nines is an estimated percentage of total body surface area burned in an
adult. The head is 9%, anterior torso 18%, posterior torso 18%, each arm 9%, each leg
18%, and groin 1%. The rule of nines is often used at the initial evaluation and should
be recalculated within the first 72 hours.
Carbon monoxide (CO) has a much stronger bond to Hgb than oxygen
does. Consequently, CO displaces oxygen from Hgb, causing hypoxia that is not
reflected by a pulse oximeter reading. The nurse's primary action is to administer highly
concentrated (100%) oxygen using a nonrebreather mask at 15 L/min in order to
reverse this displacement of oxygen.