HESI ADVANCED CLINICAL CONCEPTS
• ARDS is an unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems. The mortality rate is high (50%)
• In ARDS, a common laboratory finding is lowered PO2. However, these clients are not very responsive to h...
hesi advanced clinical concepts • ards is an unexpected
catastrophic pulmonary complication occurring in a person with no previous pulmonary problems the mortality ra
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HESI ADVANCED CLINICAL CONCEPTS
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HESI ADVANCED CLINICAL CONCEPTS
• All vasopressors/vasodilator drugs are potent and
• ARDS is an unexpected, catastrophic pulmonary dangerous and require weaning on and off. Do not
complication occurring in a person with no previous change infusion rates simultaneously.
pulmonary problems. The mortality rate is high (50%)
• A client is brought into the hospital suffering shock
• In ARDS, a common laboratory finding is lowered PO2. symptoms as a result of a bee sting. What is the
However, these clients are not very responsive to high first priority?
concentrations of oxygen.
• Think about the physiology of the lungs by
remembering PEEP: Positive End Expiratory Pressure is
the instillation and maintenance of small amounts of
air into the alveolar sacs to prevent them from
collapsing each time the client exhales. The amount
of pressure can be set with the ventilator and is
usually around 5 to 10 cm of water.
• Suction only when secretions are present.
• Before drawing arterial blood gases from the radial
artery, perform the Allen test to assess collateral
circulation. Make the client’s hand blanch by
obliterating both the radial and 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, and the
radial artery can be used for puncture. If the Allen test
is negative, repeat on the other arm. If this 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.
• If the client does not have O2 to his/her brain, the rest
of the injuries do not matter because death will occur.
However, they must be removed from any source of
imminent danger, such as a fire.
• PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory
failure.
• A child in severe distress should be on 100% O2.
• Early signs of shock are agitation and restlessness
resulting from cerebral hypoxia.
• If cardiogenic shock exists with the presence of
pulmonary edema, i.e., from pump failure, position
client to REDUCE venous return (HIGH FOWLER’s with
legs down) in order to decrease venous return further
to the left ventricle.
• Severe shock leads to widespread cellular injury and
impairs the integrity of the capillary membranes. Fluid
and osmotic proteins seep into the extra vascular
spaces, further reducing cardiac output. A vicious
cycle of decreased perfusion to ALL cellular level
activities ensues. All organs are damaged, and if
perfusion problems exist, the damage can be
permanent.
1
, Maintaining an open airway (the allergic reaction nitroglycerin tablets 5 minutes apart over a
damages the lining of the airways causing edema). 150minute period.
Also, keep the client warm without constricting
clothing; keep legs elevated (not Trendelenburg
because the weight of the lower organs restricts
breathing).
• Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild
• Epinephrine: 1:10,000, or 5ml IV for severe
• Volume expanding fluids are usually given to clients
in shock. However, if the shock is cardiogenic,
pulmonary edema may result.
• Drugs of choice for shock
- Digitalis preparations: Increase the contractility of the
heart muscle
- Vasoconstrictors (Levophed, Dopamine): Generalized
vasonconstriction to provide more available blood to
the heart to help maintain cardiac output.
• A common volume-expanding substance is plasma
and possibly whole blood.
• You are caring for a woman who was in severe
automobile accident several days ago. She has
several fractures and internal injuries. The
exploratory laparotomy was successful in controlling
the bleeding. However, today you find that this client
is bleeding from her incision, short of breath, has a
weak thready pulse, has cold and clammy skin, and
hematuria.
- What do you think is wrong with the client, and what
would you expect to do about it?
- These are typical signs and symptoms of DIC crisis.
Expect to administer IV heparin to block the
formation of thrombin (Coumadin does not do this).
However, the client described is already past the
coagulation phase and into the hemorrhagic phase.
Her management would be administration of clotting
factors along with palliative treatment of the
symptoms as they arise. (Her prognosis is poor).
• NCLEX-RN questions on CPR often deal with
prioritization of actions. Question: What actions are
required for each of the following situations?
- A 24-year old motorcycle accident vistim with a
ruptured artery if the leg is pulseless and apneic.
- A 36-year old first time pregnant woman who arrests
during labor.
- A 17-year old with no pulse or respirations who is
trapped in an overturned car, which is starting to
catch fire.
- A 40-year old businessman who arrests two days
after a cervical laminectomy.
• WHEN TO SEEK EMERGENCY MEDICAL SERVICE (EMS)
- The American Heart Association recommends that
those with known angina pectoris seek emergency
medical care if chest pain is NOT relieved by three
2
,- A person with previously unrecognized coronary
disease experiencing chest pain persisting for 2 • Fluid Volume Deficit: Dehydration
minutes or longer should seek emergency medical - Elevated BUN: The BUN measures the amount of urea
treatment. nitrogen in the blood. Urea is formed in the liver as
the end product of protein metabolism. The BUN is
• It is important for the nurse to stay current with the directly related to the metabolic function of the liver
American Heart Association’s guidelines for Basic Life and the excretory function of the kidneys.
Support (BLS) by being certified every two years as
required.
• If one rescuer is performing CPR, 1 15:2 ratio of
compression to ventilations is performed for 4 cycles,
then reassess for breathing and pulse. If two rescuers
are performing CPR, a 15:2 ratio is now recommended
for compressions to ventilations. Perform for 15 cycles
with a 100/min compression rate. When trading off,
start with compressions.
• Initiate CPR with BLS guidelines immediately, then
move on to Advanced Cardiac Life Support (ACLS)
guidelines.
• When significant arterial acidosis is noted, try to
reduce PCO2 by increasing ventilation, which will
correct arterial, venous, and tissue acidosis.
Bicarbonate may exacerbate acidosis b producing
CO2. Thus, the ACLS guidelines have recommended
bicarbonate NOT be used unless hyperkalemia and/or
preexisting acidosis is documented.
• Infants/prematures may have problems with the
following that can predispose to arrest: Beware of the
“H’s” – hypoxia, hypoglycemia, hypothermia,
increased H+ (metabolic and/or respiratory acidosis),
hypercoagulability (if polycythemia exists).
• Changes is osmolarity cause shifts in fluid. The
osmolarity of the extracellular fluid (ECF) is almost
entriely due to sodium. The osmolarity of intracellular
fluid (ICF) is related to many particles, with potassium
being the primary electrolyte. The pressures in the
ECF and the ICF are almost identical. If either ECF or
ICF change in concentration, fluid shifts from the area
of lesser concentration to the area of greater
concentration.
• Dextrose 10% is a hypertonic solution and should be
administered IV.
• Normal saline is an isotonic solution and is used for
irrigations, such as bladder irrigations or IV flush lines
with intermittent IV medication.
• Use only isotonic (neutral) solutions in irrigations,
infusions, etc., unless the specific aim is to shift fluid
into intracellular or extracellular spaces.
• Potassium imbalances are potentially life-threatening,
must be corrected immediately. A low magnesium
often accompanies a low K+, especially with the use
of diuretics.
3
, - Creatinine, as with BUN, is excreted entirely by the
kidneys and is therefore directly proportional to renal • REMEMBER to monitor the client as well as the
excretory function. However, unlike BUN, the machine! If the EKG monitor shows a severe
creatinine level is affected very little by dehydration, dysrhythmia, but the client is sitting up quietly
malnutrition, or hepatic function. The daily production watching a TV without any sign of
of creatinine depends on muscle mass, which
fluctuates very little. Therefore, it is a better test of
renal function than is the BUN. Creatinine is generally
used in conjunction with the BUN test and they
normally are in a 1:20 ratio.
- Serum osmolality measures the concentration of
particles in a solution. It refers to the fact that the
same amount of solute is present, but the amount of
solvent (fluid) is decreased. Therefore, the blood can
be considered “more concentrated.”
- Urine osmolality and specific gravity increase.
• Check the IV tubing container to determine the drip
factor because drip factors vary. The most common
drip factors are 10, 12, 15, and 60 drops per milliliter.
A microdrip is 60 drops per milliliter.
• Flushing a saline lock requires approximately 1 ½
times the amount of fluid that the tubing will hold in
order to efficiently flush the tubing. REMEMBER to use
sterile technique to prevent complications such as
infiltration, emboli and infection.
• A pH of less than 6.8 or more than 7.8 is NOT
COMPATIBLE WITH LIFE.
• The acronym ROME can help you remember:
Respiratory, Opposite, Metabolic, Equal.
• Review the order of blood flow to the heart:
- Unoxygenated blood flows from the superior and
inferior vena cava into the right atrium, then to the
right ventricle. It flows out of the heart through the
pulmonary artery, to the lungs for oxygenation. The
pulmonary vein delivers oxygenated blood back to
the left atrium, then to the left ventricle (largest,
strongest chamber) and out the aorta.
- Review the three structures that control the one-way
flow of blood through the heart:
1. Valves Atrioventricular valves Tricuspid (right
side)
Mitral (left side)
Semilunar valves Pulmonary (in
pulmonary artery) Aortic (in aorta)
2. Cordae Tendinae
3. Papillary muscles
• Since the T waves represents repolarization of the
ventricle, this is a critical time in the heartbeat. This
action represents a resting and regrouping stage so
that the next heartbeat can occur. If defibrillation
occurs during this phase, the heart can be thrust
into a life-threatening dysrhythmia.
• Observe the client for tolerance of the current
rhythm. This information is the most important data
the nurse can collect on the client with an arrythmia.
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