Which action should the nurse take before drawing a sample for ABGs from the
radial artery?
Perform the Allen test to assess collateral circulation. Make the client’s hand
blanch by obliterating both the radial and the ulnar pulses. Then release the
pressure over the ulnar artery only. If flow through the ulnar artery is good,
flushing will be seen immediately. The Allen test is then positive; therefore, the
radial artery can be used for puncture. If the Allen test is negative, repeat on the
other arm. If that test is also negative, seek another site for arterial puncture. The
Allen test ensures collateral circulation to the hand if thrombosis of the radial
artery should follow the puncture.
What PO 2 value indicates respiratory failure in adults?
PO2 below 60 mm Hg
What blood value indicates hypercapnia?
PCO2 above 45 mm Hg
Identify the condition that exists when the PO 2 is less than 60 mm Hg (acute
hypoxemia), the carbon dioxide tension rises above 50 mm Hg (acute hypercarbia,
hypercapnia) and the pH drops below 7.35, or both.
Acute Respiratory Failure
List three symptoms of respiratory failure in adults.
Dyspnea/tachypnea; intercostal and sternal retractions; cyanosis
List four common causes of respiratory failure in children.
Congenital heart disease; infection or sepsis; respiratory distress syndrome;
aspiration; fluid overload or dehydration
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What percentage of O2 should a child in severe respiratory distress receive?
100%
- Define shock.
- Widespread, serious reduction of tissue perfusion, which leads to generalized
impairment of cellular function.
What is the most common cause of shock?
hypovolemia
. What causes septic shock?
Release of endotoxins by bacteria, which act on nerves in vascular spaces in the
periphery, causing vascular pooling, reduced venous return, and decreased cardiac
output and result in poor systemic perfusion
What is the goal of treatment for hypovolemic shock
Quick restoration of cardiac output and tissue perfusion.
Infant and children
For infants and children provide chest compressions that depress the chest at least
1/3 of the anterior posterior diameter of the chest, use chest compression rate of
∼100 to 120/min for infants and children.
- Single rescuers compression to ventilation rate 30:2; two rescuers 15:2
What intervention is used to restore cardiac output when hypovolemic shock
exists? In this answer include the word warm: Rapid infusion of warm volumeexpanding fluids
Rapid infusion of volume-expanding fluids.
. It is important to differentiate between hypovolemic and cardiogenic shock. How
might the nurse determine the existence of cardiogenic shock?
History of MI with left ventricular failure or possible cardiomyopathy, with
symptoms of pulmonary edema.
If a client is in cardiogenic shock, what might result from administration of
volume-expanding fluids, and what intervention can the nurse expect to perform in
the event of such an occurrence?
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Pulmonary edema; administer medications to manage preload, contractility, and/or
afterload. For example, to decrease afterload, nitroprusside may be administered
List five assessment findings that occur in most shock victims.
Epinephrine, dopamine, dobutamine, norepinephrine, or isoproterenol.
Once circulating volume is restored, vasopressors may be prescribed to increase
venous return. List the main drugs that are used. Include milrinone in the answer to
9.
- What is the established minimum renal output per hour?
30 mL/h
List four measurable criteria that are the major expected outcomes of a shock
crisis.
BP mean of 80 to 90 mm Hg;
Po2 greater than 50 mm Hg;
CVP 2 to 6 mm HG H2O;
urine output at least 30 mL/h.
. Define DIC
A coagulation disorder in which there is paradoxical thrombosis and hemorrhage.
What is the effect of DIC on PT, PTT, platelets, and FSPs.
PT, prolonged; PTT, prolonged; platelets, decreased; FSPs, increased.
. What medication is used in the treatment of DIC?
Heparin.
Name four nursing judgment measures to prevent injury in clients with DIC.
Gently provide oral care with mouth swabs. Minimize needle sticks and use the
smallest gauge needle possible when injections are necessary. Eliminate pressure
by turning the client frequently. Minimize the number of BP measurements taken
by cuff. Use gentle suction to prevent trauma to mucosa. Apply pressure to any
oozing site.
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The pediatric cardiac arrest algorithm known as the reversible causes include the
four “H’s”:
hypoxia, hypovolemia, hyperkalemia, hypokalemia, other electrolyte disturbances,
and the four “Ts”: Tension pneumothorax, cardiac tamponade, drug toxicity and
therapeutics, thromboembolism, and other outflow obstructions.
Infant and Children CPR
For infants and children provide chest compressions that depress the chest at least
1/3 of the anterior posterior diameter of the chest, use chest compression rate of
∼100 to 120/min for infants and children.
- Single rescuers compression to ventilation rate 30:2; two rescuers 15:
Hands-Only CPR, High-Quality CPR, and In-Hospital CPR
Consists of two easy steps:
- Call 9-1-1 (or send someone to do that)
- Push hard and fast in the center of the chest
The focus is on early, high-quality chest compressions. The healthcare provider
includes chest compressions before rescue breaths. “C-A-B” (Chest Compression,
Airway, and Breathing) is now used for adults and children, whereas steps for the
newborns remain “A-B-C” (Airway, Breathing, and Circulation).
Automated external defibrillators (AEDs) can greatly increase a cardiac arrest
victim’s chances of survival. To minimize the time to defibrillation for cardiac
arrest victims, deployment of AEDs should not be limited to only trained people
(although training is still recommended).
High-Quality CPR
High-quality CPR should be performed by anyone—including bystanders. There
are five critical components: - Minimize interruptions in chest compressions
- Provide compressions of adequate rate and depth
- Avoid leaning on the victim between compressions
- Ensure proper hand placement