ER Nursing
Review antidotes for common overdose medications:
Barbiturates,Benzodiazepines,Alcohol,CNS stimulants,Tylenol,Opiates
Barbiturates:None: consider activated charcoal or hemodialysis
Benzodiazepines:Flumazenil/Romazecon
Alcohol: Supportive measures, consider withdrawals
CNS stimulants: Supportive measures, antihypertensives, sedatives, Beta blocker
Tylenol: N acetylcysteine/mucoyst
Opiates:Narcan
Describe s/s of effective treatment in shock patients:
Improved MAP to 65 mmg HG, improved mentation, improved urine output, Lactate levels trending downward, improved bowel sounds, improved BUN, Creatinine, improved liver enzymes (AST/ALT), improved cardiac contractility.
Which of the following is an indicator of mitral valve stenosis?
The primary purpose of percutaneous coronary intervention (PCI) is:
Improve myocardial oxygen supply by opening blocked arteries and providing access for additional interventions such as balloon angioplasty and stenting, allowing the balloon to compress plaque and stent to provide support for the vessel to remain patent.
Which clinical sign is most indicative of cardiac tamponade?
jugular venous distension (JVD), muffled heart tones, hypotension
Which of the following is the highest priority nursing intervention when administering thrombolytic therapy?
Monitoring for signs of bleeding including changes in LOC.
Prioritize care for shock patients:
ID patient risk factors for specific types of shock
Recognize EARLY vs Late signs and symptoms using diagnostics + assessment
Initial treatment to identify and treat underlying cause of shock (pump problem, pipes problem, plasma/volume problem)
Maintain circulating volume and tissue perfusion
Prevent organ failure
Protect organs distal to dysfunction
Ongoing evaluation to determine if interventions are effective (MAP, sp02 etc).
Describe a common symptom of infective endocarditis with initial nursing intervention for IE.
Nursing intervention: Blood cultures from 2-3 sites PRIOR to antibiotic administration
•New or worsening systolic murmur
•Shortness of breath
•Petechiae of conjunctiva, lips, oral mucosa, palate, ankles, feet antecubital or popliteal locations
•Osler’s nodes-painful red or purple lesions to fingertips or toes
•Janeway’s nodes-painless, flat, small reddened spots on fingertips, palms, soles of feet, toes
A patient enters the ER complaining of chest pain that has not been relieved by oral nitroglycerin tabs x 3. List appropriate primary interventions:
-12 lead EKG to confirm STEMI or NSTEMI (remember all MI's are treated as ST elevated MIs until proven otherwise by 12 lead EKG)
-Vital signs and continuos telemetry
-IV access
-Morphine for pain when UNRELIEVED by nitroglycerin to decrease oxygen demands
-Oxygen for spo2 < 92% to increase 02 supply
-Monitor BP for hypotension
-Consider thrombolytic therapy if STEMI confirmed and no access to PCI
-Restore perfusion
*Consider MONA TASS -not in that specific order (morphine, oxygen, nitro, aspirin,thrombolytic, anticoagulants, sedatives)
Liste differentiating s/s of various levels of heat and cold related injury:
Heat cramps, Heat exhaustion, Heat stroke
Mild Hypothermia, Moderate hypothermia,severe hypothermia
Heat cramps: Muscle contractions, thirst, treat with sports drinks, water, mild analgesics
Heat exhaustion: Altered mental status, pale ashen skin, profuse sweating, temp 99.6-105.8F, tachycardia, most sheet, admit if high
Heat Stroke: altered mental status, no seating, hypotension,tea colored urine, hot dry skin, large bore IV, cool bath, core temp, control shivering, labs, support ABC
Mild Hypothermia: shivering, lethargy, confusion, irrational behavior, minor HR changes. T 90-95 F
Mod Hypothermia: Shivering stops at 86 F, muscle rigidity, hypotension, bradycardia, hypovolemia, acidosis, T 82-90F
Severe Hypothermia: Patient appears dead, systems slowed, reflexes absent, pupils fixed, Vfib or PEA
Also consider treatment for each stage!
Describe the 4 levels of triage categories for disaster triage AND primary survey for Trauma/Non Trauma Patients
Black -Expectant-unlikely to survive
Red-Immediate-victim helped with IMMEDIATE intervention (includes ABCs)
Yellow-Delayed-transport can be delayed
Green-Minor-relatively minor injuries (walking wounded)
A-airway, alertness, C Spine
B-Breathing
C-Circulation
D-Disability- neuro, Glasgow Coma Scale
E- Environment + Exposure
F-Family presence + Full set of vitals with manual BP
G-Gadgets- get ready for further evaluation
L-Lab
M-Monitor Heart
N-Naso/oro gastric tubes
O-Oxygenation
P-Pain assessment managment
**remember to assess interventions on that system before you move on to the next!
Septic Shock treatment and correct order of implementation
Blood, sputum, and urine cultures
Broad Spectrum antibiotics
Fluid resuscitation (fill the tanke before vasopressors)
Vasopressors
Compare and contrast care for bioprosthetic valves vs mechanical valves.
Bioprosthetic: No anticoagulation, shorter durability, lower risk for bleeding, use in patients with contraindicated anticoagulation. It cannot be used in Aortic valve replacement due to increased pressure within the aorta.
Mechanical: Lifetime anticoagulation, longer durability, increased risk of thrombus.
List priority nursing interventions while caring for a patient following a percutaneous coronary intervention:
-Monitor for signs of bleeding or hematoma at the insertion site
-Monitor for s/s of internal bleeding including hypotension
-Monitor continuous telemetry and vs per post operative protocol
-Monitor for any signs of ongoing chest pain
-Encourage fluids to flush contrast out of system
-Provide antiplatelet therapy when indicated 9
-Patient education, including bedrest, stent placement, medications, heart-healthy diet, tobacco cessation, short term activity restrictions
Describe contraindications and monitoring needed for thrombolytics during MI.
Contraindications:
Active internal bleeding, Hx of brain bleedin, brain or spinal surgery within 2 months, recent ischemic stroke with thrombolytic therapy, Peptic ulcer disease, current anticoagulant use, high fall risk, majory surgery within 3 weeks, pregnancy, recent internal bleeding within 2-4 weeks, traumatic CPR.
Monitoring:
Signs of reperfusion (ST segment returning to baseline), reperfusion dysrhythmias, s/s of intracranial bleedin,g including mental status, vital signs,
Describe appropriate nursing care for a bite wound for the following animals:
1)Dog bite
2)Venomous snake
1) Clean wound, consider tetanus, leave wound open, prophylactic antibiotics for wounds over joints, > 6 hours old, bites to hand/foot
2) Keep patient calm, remove constructive items, don to place a tourniquet, attain antivenom
Remember, this will drive treatment and interventions
Remember ABC's and oxygenation is always a priority
Cardiogenic:
MI, dysrhythmias, valve disorder, cardiomyopathy, blunt cardiac injury (contusion),trauma patients
Hypovolemic: Fluid loss, n/v, hemorrhage, third spacing (leading to decreased CO)
Distributive Shock:
Spinal cord injury, allergy (environmental, medication)
Septic: Bacterial infections, infective endocarditis,
Name the inflammatory heart condition and related diagnosis that may lead to cardiac tamponade:
Diagnosis: pericardial effusion, recent MI, Autoimmune reaction, post-cardiac surgery
Describe use of Nitroglycerin and Morphine in ACS patients:
Nitroglycerin: dilates coronary arteries to improve blood flow and relieve chest pain
Morphine: relieves pain if unrelieved by nitro, reduces preload and afterload and oxygen demand
Describe the expected results of administering vasodilator/antihypertensive medications:
-Decreased systemic vascular resistance due to vasodilation
-may alter afterload
-decrease myocardial workload
-relieve chest pain
-Increase perfusion if partial obstruction is occuring
Describe the ABCDEFG Primary survey:
A: Airway/Cspine if clear move to B
B: Breathing if clear/adequate move to C
C: Circulation **if uncontrolled hemorrhage this would be primary ! If controlled move to D
D: Disability/neuro if clear movement E
E: Environment and Exposure (expose patient, ensure warm environment if clear move to F
F: Family support *Full set of Vitals (manual BP)
if clear move to G
G: Gadgets/get ready for further evaluation (diagnostics etc)
***if you provide intervention, you need to go back and reassess!!
Recall unique assessment findings for Shock patients
Neurogenic: Bradycardia, dry skin, flaccid paralysis, resp arrest if injury above C4
Anaphylaxis: Wheezing, stridor, angioedema, edema to the larynx or epiglottis, hives
Septic: Related respiratory problem (acidosis or alkalosis, GI bleeding, decreased EF
Obstructive Shock: JVD, pulsus paradoxus, s/s of pericardial tamponade or tension pneumothorax
Describe the causes of Mitral Valve Regurgitation/insufficiency
Rheumatic fever, infective endocarditis, MI, Marfan Syndrome, dilated cardiomyopathy
Describe possible complications post CABG:
-Bleeding
-Infection
-Decreased CO
-Stroke
-Pulmonary complications
-Electrolyte imbalancce
Describe symptoms of mitral valve stenosis:
Right sided heart failure symptoms:
-Hepatomegaly
-JVD
-Pitting Edema
-Shortness of breath on exertion
- pulmonary congestion
-Palpitations
- fatigue