CRITICAL CARE o Occlude the radial and ulnar arteries
using firm pressure
JAW THRUST MANEUVER
• Clinical situations involving trauma should
follow ABC: Airway, Breathing, and
Circulation.
• Airway assessment is particularly critical in
clients with injuries to the head, neck, and
upper back.
• Injury to the upper back should be treated
as spinal trauma until the client has been
cleared by an Advanced Trauma Life
Support-qualified health care provider.
• Until the spine is appropriately assessed,
the client should be placed on a backboard
and stabilized.
• The nurse should use the jaw-thrust
maneuver to avoid movement of an
unstable spine. One provider should
stabilize the cervical vertebra allowing the
second provider to articulate the jaw
independently of the spinal column.
ALLEN’S TEST
• The radial artery site at the wrist is
preferred for collecting an arterial blood gas
sample because it is near the surface, is
easy to palpate and stabilize, and has good
collateral supply from the ulnar artery. The
patency of the ulnar artery can be
confirmed with a positive modified Allen's
test.
• The modified Allen's test includes the
following steps:
o Instruct the client to make a tight fist (if
possible)
o Instruct the client to open the fist; the
palm will be white if both arteries are
sufficiently occluded
o 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)
• If the Allen's test is positive, the arterial
blood gas can be drawn; if negative and the
palm does not return to a pink color, an
alternate site (eg, brachial artery, femoral
artery) must be used.
DIABETIC KETOACIDOSIS
• DKA is a life-threatening complication of
type 1 diabetes characterized by
hyperglycemia (>250 mg/dL [13.9 mmol/L])
resulting in ketosis, a metabolic acidosis.
• Glucose cannot be taken out of the
bloodstream and used for energy without
insulin, which individuals with type 1
diabetes cannot produce.
• Similar to a state of starvation, the body
begins to break down fat stores
into ketones, causing a metabolic acidosis
(low pH and low HCO3).
• As a compensatory mechanism, this client
has deep and rapid respirations
with fruity/acetone smell (Kussmaul
respirations) in an attempt to reduce
carbon dioxide levels by inducing a
respiratory alkalosis to partially compensate
 for the ketoacidosis, which has nearly
normalized the pH.
EXTUBATION
• 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.
PHLEBOSTATIC AXIS ARTERIAL LINE
• The phlebostatic axis is an external
anatomical point on the chest at the level of
the atria of the heart (fourth intercostal
space at the midaxillary line or midway
point of the anterior posterior diameter of
the chest).
• It is used as a reference point for correct
placement of the zeroing point of the
transducer when measuring continual
arterial blood pressure (BP), central venous
pressure (CVP) using a central line, and/or
cardiopulmonary pressures via a pulmonary
artery (Swan-Ganz) catheter.
• The nurse places the transducer and marks
the chest at the phlebostatic axis, which
helps to assure accuracy of measurement.
• After it is placed, the zero reference
stopcock of the transducer is "leveled," or
aligned with the level of the atrium, using a
ruler or carpenter's level. If the zeroing
stopcock is placed below this level, falsely
high readings occur; if it is too high, falsely
low readings are obtained.
• The phlebostatic axis is also used as a
reference point for the upper arm when
measuring BP indirectly using a
noninvasive BP device or the auscultatory
method with sphygmomanometer and
stethoscope. If the upper arm is above or
below this level, the BP reading will be
inaccurate.
INCREASE ICP
• Metabolic demands (eg, pain, straining,
agitation, shivering, fever, hypoxia)
increase brain blood supply and raise
ICP. Nursing interventions to control ICP
include:
o Elevating the head of the bed to 30
degrees with the head/neck in
a neutral position to reduce venous
congestion
o Administering stool softeners to
reduce the risk of straining (eg,
Valsalva maneuver)
o Managing pain well while monitoring
sedation
 o Managing fever (eg, cool sponges, ice,
antipyretics) while preventing shivering
o Maintaining a calm environment with
minimal noise (eg, alarms, television,
hall noise)
o Ensuring adequate oxygenation
o Hyperventilating and preoxygenating
the client before suctioning; reducing
CO2 (a potent cerebral vasodilator) by
hyperventilation induces
vasoconstriction and reduces ICP
• 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.
• The nurse should suction a maximum of 10
seconds and only as necessary to remove
secretions. Prolonged suctioning increases
ICP.
DOPAMINE
• Dopamine (Intropin) is 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, dysrhythmia
s, and myocardial ischemia. A heart rate
of 120/min may indicate that the dopamine
infusion needs to be reduced
NEAR DROWNING
• 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
• 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.
• 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 parasympathetic nervous system (PNS)
clients. remains intact.
• The imbalance of activity between the SNS
and PNS results in massive
vasodilation and pooling of blood in the
ARTERIAL BLOOD GAS
venous circulation,
causing hypotension and bradycardia,
the characteristic manifestations of
neurogenic shock.
• Warm, dry skin is more likely to be present
in neurogenic shock; cool, clammy skin is
not a characteristic manifestation

BASIC LIFE SUPPORT

NEUROGENIC SHOCK

• All members of the health care team must

follow basic life support guidelines to
perform cardiopulmonary
resuscitation (CPR) for clients
experiencing cardiac arrest. Essential
components of adult CPR include:
o Chest compressions are performed at a
rate of 100-120/min and a depth of 2.0-
• Neurogenic shock belongs to the group 2.4 inches (5-6 cm), allowing complete
of distributive (vasodilatory) shock. It chest recoil between compressions
affects the vasomotor center in the medulla
o Defibrillator pads are placed on
and causes a disruption in the sympathetic
the right upper chest, just below the
nervous system (SNS); the
clavicle, and on the left lateral chest,
 near the anterior axillary line below the
nipple line
RAPID RESPONSE TEAM
• The rapid response team is activated to
marshal additional experienced and
specialized resources for an acute need to
try to prevent a client from deterioration into
a code/arrest situation. The team has
critical care expertise to provide immediate
attention to unstable clients in noncritical
care units and usually consists of a
respiratory therapist, a critical care nurse,
and a physician or advanced practice
registered nurse.
• Recommended criteria to consider
according to the Institute for Healthcare
Improvement include the following:
o Any provider worried about the client's
condition OR
o 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
➢ Oxygen saturation <90 despite
oxygen
➢ Urine output <50 mL/4 hr
➢ Level of consciousness
TORSADES DE POINTES
• Torsades de pointes (ie, "twisting of the
points") is a polymorphic ventricular
tachycardia characterized by QRS
complexes that change size and shape in a
characteristic twisting pattern.
• Torsades de pointes is usually due to
a prolonged QT interval (more than half the
RR interval), which is the result of
electrolyte imbalances,
especially hypomagnesemia, or some
medications. The first-line treatment is IV
magnesium. Treatment may also include
defibrillation and discontinuation of any QT-
prolonging medications.
POSITIVE PRESSURE VENTILATION
• 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).
MALIGNANT HYPERTHERMIA
• Malignant hyperthermia (MH) is a rare,
life-threatening inherited muscle
abnormality that is triggered by certain
drugs used to induce general
anesthesia 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 (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)
COPD
• An exacerbation of COPD is 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 CO2 level and BIPAP
effectiveness.
• Altered mental status poses the greatest
threat to a client's survival as it can lead to
decreased protective reflexes (eg, gag,
swallow, cough), periods of apnea, and
airway compromise
HYPOVOLEMIC SHOCK
• 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).
THIRD SPACING
• 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
CERVICAL SPINE INJURY
• The initial priorities for a client with a
suspected cervical spine injury are to
ensure a patent airway and immobilize the
spine to prevent further injury. This
includes applying a rigid hard collar,
placing the client on a firm surface (eg, a
backboard), and moving the client as a
unit (logrolling) if required
• A soft foam cervical collar does not provide
immobilization. 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.
• After immobilizing the client, the nurse
should obtain a baseline set of vital signs to
monitor for neurogenic shock (eg,
hypotension, bradycardia, poikilothermia
[ie, inability to regulate body temperature]),
a potential complication of spinal cord
injury.
• The nurse should also assess the client's
respiratory rate, pattern, and
effort. Presence of abdominal
breathing or increased work of breathing
may indicate impending loss of
airway and require prompt rapid-sequence
intubation
CPR IN PREGNANT WOMEN
• Common causes of sudden cardiac
arrest in pregnant clients include embolism,
eclampsia, magnesium overdoses, and
uterine rupture. If cardiopulmonary
resuscitation (CPR) is required, several
modifications must be made to ensure
efficacy of the rescue efforts.
• During pregnancy, the heart is displaced
toward the left because the growing uterus
pushes upward on the diaphragm,
particularly in the third trimester. To
accommodate this displacement, the hands
should be placed on the sternum slightly
higher than usual for chest compressions
during CPR
• In addition, a gravid uterus can significantly
compress the client's vena cava and aorta,
thereby hindering effective blood flow
during CPR. The uterus should
be manually displaced to the client's left to
reduce this pressure. The nurse can also
place a rolled blanket or wedge under the
right hip to displace the uterus.
• If return of spontaneous circulation (ROSC)
does not occur after 4 minutes of
CPR, emergency cesarean section is
usually initiated. Delivery should
occur within 5 minutes of initiating CPR.
SUPRAVENTRICULAR TACHYCARDIA
• Clients with paroxysmal supraventricular
tachycardia (SVT) (regular, narrow QRS
complex tachycardia) are initially treated
with vagal maneuvers. The act of "bearing
down" as if having a bowel movement
(Valsalva) is an example of these
maneuvers and may need to be attempted
more than once. Vagal maneuvers work by
increasing intra-thoracic pressure and
stimulating the vagus nerve, which
supplies parasympathetic nerve fibers to
the heart, resulting in slowed electrical
conduction through the atrioventricular
node.
• Cardioversion (not defibrillation) is used
with this type of arrhythmia when it is
refractory to medication. Cardioversion
delivers a synchronized electrical current to
the heart. This works by stopping the
 electrical activity to the heart and briefly
allowing a normal heartbeat to return.
• Adenosine is the drug of choice to treat
SVT and has a 5- to 6-second half-life (the
time it takes for the drug to be reduced to
half of its original concentration). Placing
the IV line as close as possible, not distal,
to the heart is essential for the drug to have
full effect. Adenosine is given rapidly over
1-2 seconds and then followed by a rapid
20-mL normal saline flush. Transient
asystole is common, and clients often
experience flushing and dizziness.
MECHANICAL VENTILATOR
• Clients requiring mechanical
ventilation are at risk for a variety
of ventilator-associated
complications (eg, aspiration,
pneumonia). When caring for a client
receiving mechanical ventilation, the nurse
should:
o Monitor respiratory status (eg, lung
sounds, breathing pattern), airway
patency, and ventilator functionality (eg,
settings, alarm parameters).
o Maintain the head of the bed at 30-45
degrees to reduce aspiration risk
o 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
o Perform oral care with chlorhexidine
oral solution every 2 hours, or per
facility policy. Perform tracheal
suctioning as needed.
o Monitor correct endotracheal
tube placement by noting insertion
depth.
o Place emergency equipment at
bedside (eg, manual resuscitation bag)
• Mechanical ventilator alarms (eg, high- or
low-pressure limit) alert the nurse to
potential problems caused by a change in
the client's condition, a problem with the
artificial airway (eg, endotracheal or
tracheostomy tube), and/or a problem with
the ventilator.
• Peak airway pressure is the amount of
pressure required to deliver a tidal volume.
• Any condition that increases the peak
airway pressure can trigger the ventilator
high-pressure limit alarm. When this alarm
sounds, the nurse should assess for
conditions that increase airway
resistance and/or decrease lung
compliance, such as:
o Excessive secretions: Obstruct the
airway, increasing resistance
o Biting the endotracheal tube and
kinked ventilator tubing: Air flow is
obstructed, increasing resistance
• Any condition that decreases airway
resistance (eg, tubing disconnect,
extubation, endotracheal or tracheostomy
tube cuff leak) can trigger the low-pressure
limit alarm.
GUILLAN-BARRE SYNDROME
• Guillain-Barré syndrome (GBS) is 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.
NEUROLOGIC INJURY
• 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.
DEFIBRILLATION
• 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
FROSTBITE
• 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:
o Remove clothing and jewelry to prevent
constriction.
o Do not massage, rub, or squeeze the
area involved. Injured tissue is easily
damaged
 o 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
o Avoid heavy blankets or clothing to
prevent tissue sloughing.
o Provide analgesia as
the rewarming procedure is extremely
painful
o As thawing occurs, the injured area will
become edematous and may
blister. Elevate the injured area after
rewarming to reduce edema
o Keep wounds open immediately after a
water bath or whirlpool treatment and
allow them to dry before
applying loose, nonadherent, sterile
dressings
o Monitor for signs of compartment
syndrome.
BASILAR SKULL FRACTURE
• Cerebrospinal fluid (CSF) rhinorrhea (or
CSF otorrhea) 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.
PEDIATRIC AED
• An automated external defibrillator
(AED) should be used as soon as it is
available.
• Pediatric AED pads or a pediatric dose
attenuator should be used for children age
birth to 8 years if available.
• Standard adult pads can be used as long
as they do not overlap or touch.
• If adult AED pads are used, one should be
placed on the chest and the other on
the back ("sandwiching the heart").
POSITIVE END EXPIRATORY PRESSURE
• 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.
VENTRICULAR TACHYCARDIA
• Clients in 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).
• Oxygen saturation should be assessed
after the presence of a pulse has been
established.
• CPR and defibrillation should be initiated
only in a client who is pulseless.
GASTRIC LAVAGE
• 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).
• Intubation and suction supplies should
always be available at the bedside during
GL in case the client develops aspiration or
respiratory distress
• GL is usually 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.
• During GL, clients should be placed on their
side or with the head of bed elevated to
minimize aspiration risk.
• GL 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.
PULSE OXIMETER
• The erratic pulse oximeter tracing is
representative of an artifact
plethysmograph waveform caused by
motion.
• When an electronic assessment reading is
questionable, the nurse should always
assess the client first for possible etiology.
• The assessment includes the client's
oxygenation and perfusion status (skin
temperature, color), the level of
consciousness (in sedated clients), and
restlessness or agitation. This assessment
data guides the nurse in the correct
analysis of the tracing.