NUR 3032 UWORLD REVIEW COMPLETE SOLUTION
Treatment of frostbite should include the following:
Care of the client with frostbite focuses on
... [Show More] preventing further injury and reducing pain. This includes removing items that can cause constriction or sloughing; no massaging or rubbing of the injured area; providing warm water soaks and analgesia; elevating injured areas; applying loose, nonadherent, sterile dressings; and monitoring for compartment syndrome.
Rapid response criteria for unstable clients in a nonacute care setting usually include sudden, significant changes that do not respond to treatment.
• An acute change in any of the following:
Heart rate <40 or >130/min
Systolic blood pressure <90 mm Hg
Respiratory rate <8 or >28/min (Option 4)
Oxygen saturation <90 despite oxygen
Urine output <50 mL/4 hr
Level of consciousness (Option 5)
Positive pressure ventilation causes increased intrathoracic pressure and reduced venous return and cardiac output, which can result in hypotension.
Fluid and/or sodium retention usually occurs about 48-72 hours after initiation of PPV due to: (1) increased intrathoracic pressure and decreased cardiac output that stimulate the kidneys to release renin; (2) physiologic stress that leads to the release of antidiuretic hormone and cortisol; and (3) breathing through the ventilator's closed circuitry, which decreases insensible loss associated with respiration.
Systemic inflammatory response syndrome (SIRS) occurs when the body undergoes a major insult (eg, trauma, infection, burns, hemorrhage, multiple transfusions). Stimulation of the immune response leads to activation of white blood cells (WBCs), release of inflammatory mediators, increased capillary permeability, and inflammation of organs. The sepsis continuum progresses in severity from sepsis, to severe sepsis, to septic shock, to multiple organ dysfunction (MODS).
Sepsis is an exaggerated systemic inflammatory response associated with a documented or suspected infection. Severe sepsis is sepsis complicated by organ dysfunction. Septic shock is severe sepsis with hypotension despite fluid resuscitation. MODS occurs in relation to decreased perfusion and is the end point of the sepsis continuum. It is important for the nurse to recognize manifestations of SIRS to promote early recognition, prevention, and treatment of infection and to limit its progression to MODS.
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 (PaCO2 <32 mm Hg [4.3 kPa])
• Leukocytosis (WBC count >12,000/mm3 [12.0 x 109/L] or 10% immature neutrophils [bands])
Neurogenic shock/distributive shock can occur from vasodilation soon after spinal injury (T6 or higher). Vascular dilation with decreased venous return to the heart is present due to loss of innervation from the spine. Classic symptoms are hypotension, bradycardia, and pink and dry skin. The hypotension must be treated with isotonic fluids to maintain vital organ perfusion. The hypotension must be treated with isotonic fluids to maintain vital organ perfusion.
Arterial Line pressure 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.
1- Check for hemorrhage at connection site
2- Flush the arterial line system (square wave test) 3- Level the transducer at pt’s phlebostatic axis
4- Zero the monitor
5- 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.
Emergency department care of near-drowning victims includes advanced airway management, aggressive oxygenation, establishing IV access and administering IV fluids (warmed if hypothermic), and monitoring for cardiac arrhythmias and fluid imbalances. (warm blankets, mechanical ventilation, warm IV fluids).
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 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.
Cardiac monitoring and gentle handling of the client are a high priority with hypothermia. The cold myocardium is extremely irritable and prone to dysrhythmias. The nurse should anticipate defibrillation in these clients.
The client's central venous pressure (CVP) is elevated (normal value 2-8 mm Hg), indicating increased systemic circulation volume and increased right ventricular preload. Pulmonary artery wedge pressure (PAWP) is also elevated (normal value 6-12 mm Hg), indicating increased left ventricular preload. In the presence of increased CVP and PAWP, coarse crackles indicate left-sided failure. The treatment goal is to decrease fluid volume and preload. Furosemide is a loop diuretic that will decrease both left- and right-sided preload.
The priorities for a client with a suspected cervical spine injury are a patent airway and spinal immobilization. Interventions include applying a rigid hard collar
(not soft collar), placing the client on a firm surface (backboard), logrolling if the client needs to be transferred, and preventing movement of the upper extremities until imaging studies are obtained.
If there is any suspicion of spinal injury, the jaw-thrust maneuver should be used for airway assessment to avoid any shifting of unstable vertebrae and subsequent spinal cord damage.
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.
High PEEP is commonly used to prevent small airway/alveolar collapse in clients with ARDS. PEEP helps to reduce oxygen toxicity. However, high levels of PEEP (10- 20 cm H2O [7.4-14.8 mm Hg]) can cause barotrauma to the lung, resulting in a pneumothorax, and decreased venous return causes hypotension.
Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia (eg, succinylcholine). in susceptible clients. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the post-anesthesia care unit (PACU).
The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia.
MH requires emergent treatment with IV dantrolene
Succinylcholine should be discontinued. Other interventions include applying cooling blankets to reduce temperature and treating high potassium levels.
Delirium or acute cognitive dysfunction is a syndrome commonly seen in hospitalized clients; it is reversible but difficult to diagnose. Clients may manifest delirium states that can be hypoactive (eg, quiet, disorientation, change in level of consciousness, memory loss), hyperactive (eg, restlessness, agitation, hallucinations, paranoia), or mixed.
Amnesia affects short- and long-term memory loss.
dementia is gradual in onset and causes an irreversible and progressive cognitive decline.
Psychosis does not have an acute onset. Clients with this condition are usually oriented but have auditory (not visual) hallucinations.
Nursing priorities when implementing a chemical contamination emergency response:
Restricting other clients, staff, and bystanders from the victims' vicinity to protect non-affected individuals and the health care facility from the contaminant
• Donning personal protective equipment to protect the nurse when providing care (Option 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 (Option 2).
• Assessing and providing treatment of symptoms. Initial treatment is for the symptoms (eg, wheezing), regardless of the specific cause (Options 1 and 4).
Withdrawing life support, the major goal is client comfort. The primary nursing responsibility is to assess and intervene appropriately for symptoms of pain and discomfort. Morphine is commonly used to manage the dyspnea, tachycardia, and restlessness associated with withdrawing mechanical ventilator support. Intravenous benzodiazepines, (eg, midazolam, lorazepam) may be administered for additional comfort.
First responders should not manipulate or remove the impaled object. Manipulation or removal may cause further trauma and bleeding; therefore, stabilization of the object is the first priority to prevent it from moving during initial client assessment.
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 can lead to hypovolemia, decreased cardiac output, hypotension and tachycardia, and decreased urine 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.
A child with a mild traumatic brain injury (TBI) must be discharged with a responsible adult who can monitor the child's responsiveness. It is normal for a child with TBI to have a headache, trouble thinking, and irritability for up to 6 weeks. Children who were unconscious for ≥5 minutes or had amnesia for the event are usually admitted for observation. [Show Less]