Emergency and Critical Care Nursing National University: College of Nursing

Emergency Nursing & Critical Care:: Medical Surgical Nursing :: Review For Nursing Licensure

Slide 1: Emergency and Critical Care Nurse Licensure Examination Review

Slide 3: Basic life support (BLS) A means of providing oxygen to the brain, heart and other organs until
help arrives Also known as CARDIOPULMONARY RESUSCITATION

Slide 4: Basic life support (BLS) An adult is a person above age 8 A child is any person age 1 to 8 years
old An infant is anyone under 1 year

Slide 5: Basic life support (BLS) The BLS follows the A-B-C principle • A= airway • B= breathing • C=
circulation

Slide 6: Basic life support (BLS) Causes of cardiac arrest • Respiratory arrest • Direct injury • Drug
overdose • Cardiac arrhythmias

Slide 7: Basic life support (BLS) ADULT STEPS in CPR: First STEP!!! • ASSESSMENT: determine
Unresponsiveness • Assess for 5-10 seconds • Shake the victim’s shoulder and ask: “are you okay”

Slide 8: Basic life support (BLS) ADULT STEPS in CPR: Second Step • Survey the area

Slide 9: Basic life support (BLS) ADULT STEPS in CPR: Third Step • Call for HELP • Activate emergency
medical system • Note: for child and infant this is done LAST

Slide 10: Basic life support (BLS) ADULT STEPS in CPR: Fourth step • Place Victim in Supine position on a
flat firm surface • Log roll the patient when moving

Slide 11: Basic life support (BLS) ADULT STEPS in CPR: Fifth step • OPEN the airway • Head tilt-Chin Lift
method • Jaw thrust maneuver if neck injury is suspected

Slide 13: Basic life support (BLS) ADULT STEPS in CPR: Sixth step • Assess BREATHING Place ear over the
nose and mouth Look for chest movement Perform for 3-5 SECONDS

Slide 14: Basic life support (BLS) ADULT STEPS in CPR: Sixth step • Assess BREATHING If breathing: place
on side if no neck injury; DO NOT move if with neck injury If NOT BREATHING: deliver INITIALLY 2
rescue breath via mouth to mouth Then deliver 10-12 breaths/minute

Slide 15: Basic life support (BLS) ADULT STEPS in CPR: Seventh step • Assess CIRCULATION Check for the
carotid pulse on the side close to you for 5-10 SECONDS If with (+) pulse ; continue giving 10-12
breaths/minute

Slide 16: Basic life support (BLS) ADULT STEPS in CPR: Seventh step • Assess CIRCULATION If withOUT
pulse: START Chest Compression Correct hand placement: LOWER HALF of sternum one hand over the
other with fingers interlacing Depress: 1 ½ to 2 INCHES 80-100 compressions/min

Slide 17: Basic life support (BLS) ADULT STEPS in CPR: Seventh step • Assess CIRCULATION If withOUT
pulse: START Chest Compression ONE-rescuer: 15 chest: 2 breaths TWO-rescuer: 5 chest: 1 breath
DO FOUR cycles and re-assess for pulse

Nurse Licensure Examination Reviewer Dennis B. Brosola, RN, MSN

Emergency and Critical Care Nursing National University: College of Nursing
Slide 18: Basic life support (BLS) CHILD 1-8 years old AIRWAY: assess unresponsiveness and keep airway
patent by HTCL or JT BREATHING: assess for airflow and chest movement • If breathing: maintain patent
airway • If NOT breathing : deliver 2 rescue breaths by mouth to mouth • DELIVER 20 breaths/minute

Slide 19: Basic life support (BLS) CHILD 1-8 years old CIRCULATION: assess the carotid pulse • If with
pulse: continue to deliver 15-20 breaths/minute • If WITHOUT pulse: start chest compression • Correct
hand placement: lower half of sternum using heel of ONE HAND • DELIVER: 1 to 1 ½ inches 80- 100 chest
compressions/min 5:1 (do 20 cycles EMS)

Slide 20: Basic life support (BLS) INFANT Less than 1 Determine unresponsiveness AIRWAY: Place head
of infant in NEUTRAL position BREATHING: assess for rise-fall of chest and airflow • If breathing: maintain
patent airway • If NOT breathing: initiate 2 rescue breathing via mouth to mouth and nose • DELIVER 20
breaths/min SLOWLY

Slide 21: Basic life support (BLS) INFANT Less than 1 CIRCULATION: assess for pulse: The BRACHIAL pulse
is utilized!! • If with pulse: continue to deliver 20 breaths/min • If WITHOUT pulse, start chest compression
• Correct hand placement: just below the nipple line in the sternum using 2-3 fingers of one hand!! •
DELIVER: ½ to 1 inch depth 100 chest com/min 5:1 ratio (do 20 cycles EMS)

Slide 22: AIRWAY Obstruction Incomplete • Crowing sound is heard encourage to cough Complete •
Clutching of the neck • Ask: “Are you choking?” • Perform Heimlich’s

Slide 23: AIRWAY Obstruction Complete • If patient becomes unconscious: Place supine on flat surface
Perform tongue-jaw lift maneuver FINGERSWEEP to remove object Open airway and attempt
ventilation Perform Heimlich while supine Reattempt ventilation SEQUENCE: TJL finger-sweep
rescue breaths Heimlich’s TJL

Slide 24: AIRWAY Obstruction Pediatric considerations: CHILD: NEVER DO Blind Finger sweep

Slide 25: AIRWAY Obstruction Pediatric considerations: INFANT: never DO blind finger- sweep Give
five back blows in the interscapular area and turn the infant with head lower than trunk then deliver chest
thrust below the nipple line

Slide 26: AIRWAY Obstruction Obstetric considerations: Hand is placed over the middle part of
sternum: backward chest thrust If unconscious: place pillow below the RIGHT abdomen to displace
uterus

Slide 27: Shock An abnormal physiologic state where an imbalance exists between the amount of
circulating blood volume and the size of the vascular bed.

Slide 29: Pathophysiology of Shock 1. Cellular effects of shock In the absence of oxygen, the cell will
undergo Anaerobic metabolism to produce energy source and with it comes numerous by-products like
lactic acid The cell will swell due to the influx of Na and H20, mitochondria will be damaged, lysosomal
enzymes will be liberated, and then cellular death ensues.

Slide 30: Pathophysiology of Shock 2. Organ System Responses When the patient encounters
precipitating causes of shock, the circulatory function diminishes there is decreased cardiac output
Hypotension and decreased tissue perfusion will result

Nurse Licensure Examination Reviewer Dennis B. Brosola, RN, MSN

Emergency and Critical Care Nursing National University: College of Nursing
Slide 31: Shock Stages There are three stages of shock Compensatory stage Progressive stage
Irreversible stage

Slide 32: Shock Stages THE COMPENSATORY STAGE OF SHOCK In this stage, the patient’s blood pressure
is within normal limits. Patient’s blood is shunted from the kidney, skin and GIT to the vital organs- brain,
liver and muscles Manifestations of cold clammy skin, oliguria and hypoactive bowel sounds can be
assessed. Medical management includes IVF and medication Nursing management includes
monitoring of tissue perfusion & vital signs, reduction of anxiety, administering IVF/ordered medications
and promotion of safety

Slide 33: THE PROGRESSIVE STAGE OF SHOCK In this stage, the mechanisms that regulate blood pressure
can no longer compensate and the mean arterial pressure falls. The overworked heart becomes
dysfunctional. Heart rate becomes very rapid (as high as 150 bpm) Blood flow to the brain becomes
impaired, the mental status deteriorates due to decreased cerebral perfusion and hypoxia. Laboratory
findings will reveal increased BUN and Creatinine. Urinary output decreases to below 30 mL/hour.

Slide 34: Shock Stages THE PROGRESSIVE STAGE OF SHOCK Decreased blood flow to the liver impairing
the hepatic functions. Toxic wastes are not metabolized efficiently, resulting to accumulation of ammonia,
bilirubin and lactic acids. The reduced blood flow to the GIT causes stress ulcers and increased risk for
GI bleeding. Hypotension, sluggish blood flow, metabolic acidosis (due to accumulation of lactic acid),
and generalized hypoxemia can interfere with normal blood function.

Slide 35: Shock Stages THE IRREVERSIBLE STAGE OF SHOCK This stage represents the end point where
there is severe organ damage that patients do not respond anymore to treatment. Survival is almost
impossible to maintain. Despite treatment, the BP remains low, anaerobic metabolisms continues and
multiple organ failure results. Medical management is the use of life supporting drugs like epinephrine
and investigational medications.

Slide 36: Assessment of Shock Assessment Findings Skin : Cool, pale, moist in hypovolemic and cardiogenic
shock : Warm, dry, pink in septic and neurogenic shock Pulse Tachycardia, due to increased sympathetic
stimulation Weak and thready Blood pressure 1. Early stages: may be normal due to compensatory
mechanisms 2. Later stages: systolic and diastolic blood pressure drops.

Slide 37: Assessment of Shock Assessment Findings Respirations: rapid and shallow, due to tissue anoxia
and excessive amounts of CO (from metabolic Acidosis) Level of consciousness: restlessness and
apprehension, progressing to coma Urinary output: decreases due to impaired renal perfusion
Temperature: decreases in severe shock (except septic shock).

Slide 38: Management of Shock Nursing Interventions Management in all types and phases of shock
includes the following: Basic life support Fluid replacement Vasoactive medications Nutritional
support

Slide 39: Management of Shock A. Maintain patent airway and adequate ventilation. B. Promote
restoration of blood volume; administer fluid and blood replacement as ordered C. Administer drugs as
ordered D. Minimize factors contributing to shock. E. Maintain continuous assessment of the client. F.
Provide psychological support: reassure client to relieve apprehension, and keep family advised G. Provide
Nutritional support

Nurse Licensure Examination Reviewer Dennis B. Brosola, RN, MSN

Emergency and Critical Care Nursing National University: College of Nursing
Slide 41: Hypovolemic Shock This is the MOST common form of shock characterized by a decreased
intravascular volume Risk factors: external Fluid Losses Trauma, Surgery, Vomiting, Diarrhea, Diuresis, DI
Risk factors: internal fluid shifts Hemorrhage, Burns, Ascites, Peritonitis, Dehydration

Slide 42: Hypovolemic Shock Decreased blood volume decreased venous return to the heart decreased
stroke volume decreased cardiac output decreased tissue perfusion Assessment findings: cold
clammy skin, tachycardia, mental status changes, tachypnea

Slide 43: Hypovolemic Shock MEDICAL MANAGEMENT: • The major medical goals are to restore
intravascular volume, to redistribute the fluid volume, and to correct the underlying cause of fluid loss
promptly

Slide 44: Hypovolemic Shock NURSNG MANAGEMENT: • Primary prevention of shock is the most
important intervention of the nurse. • General nursing measures include- safe administration of the
ordered fluids and medications, documenting their administration and effects. The nurse must monitor
the patient for signs of complications and response to treatment. Oxygen is administered to increase the
amount of O2 carried by the available hemoglobin in the blood.

Slide 45: Cardiogenic shock This shock occurs when the heart’s ability to contract and to pump blood is
impaired and the supply of oxygen is inadequate for the heart and tissues Risk factors: Coronary factor-
Myocardial infarction Risks factors: NON coronary: • Cardiomyopathies • Valvular damage • Cardiac
tamponade • Dysrhythmias

Slide 46: Cardiogenic shock Precipitating factors will cause decreased cardiac contractility Decreased
stroke volume and cardiac output leading to 3 things: Damming up of blood in the pulmonary vein will
cause pulmonary congestion Decreased blood pressure will cause decreased systemic perfusion
Decreased pressure causes decreased perfusion of the coronary arteries leading to weaker contractility
of the heart

Slide 47: Cardiogenic shock ASSESSMENT FINDINGS: Angina, hemodynamic instability, dysrhythmias
MEDICAL MANAGEMENT: • The goals of medical management are to limit further myocardial damage
and preserve and to improve the cardiac function by increasing contractility. NURSING MANAGEMENT:
• The nurse prevents cardiogenic shock by early detection of patients at risk. • Safety and comfort
measures like proper positioning, side-rails, and reduction of anxiety, frequent skin care and family
education.

Slide 48: Circulatory shock This is also called distributive shock. It occurs when the blood volume is
abnormally displaced in the vasculature. • Septic Shock • Neurogenic Shock • Anaphylactic Shock

Slide 49: Circulatory shock Massive arterial and venous dilation allows pooling of blood peripherally
maldistribution of blood volume decreased venous return decreased stroke volume decreased cardiac
output Decreased blood pressure decreased tissue perfusion.

Slide 50: Circulatory shock Risk factors for Septic Shock • Immunosuppression • Extremes of age (<1 and
>65) • Malnourishment • Chronic Illness • Invasive procedures

Slide 51: Circulatory shock Risk factors for Neurogenic Shock • Spinal cord injury • Spinal anesthesia •
Depressant action of medications • Glucose deficiency

Nurse Licensure Examination Reviewer Dennis B. Brosola, RN, MSN

Emergency and Critical Care Nursing National University: College of Nursing
Slide 52: Circulatory shock Risk factors for Anaphylactic Shock • Penicillin sensitivity • Transfusion
reaction • Bee sting allergy • Latex sensitivity

Slide 53: SEPTIC SHOCK This is the most common type of circulatory shock and is caused by widespread
infection. The HYPERDYNAMIC PHASE • High cardiac output with systemic vasodilatation. • The BP
remains within normal limits. • Tachycardia • Hyperthermic and febrile with warm, flushed skin and
bounding pulses

Slide 54: SEPTIC SHOCK The HYPODYNAMIC or irreversible phase • LOW cardiac output with
VASOCONSTRICTION • The blood pressure drops, the skin is cool and pale, with temperature below
normal. • Heart rate and respiratory rate remain RAPID! • The patient no longer produces urine.

Slide 55: SEPTIC SHOCK MEDICAL MANAGEMENT: • Current treatment involves identifying and
eliminating the cause of infection. Fluid replacement must be instituted to correct Hypovolemia,
Intravenous antibiotics are prescribed based on culture and sensitivity.

Slide 56: SEPTIC SHOCK NURSING MANAGEMENT: • The nurse must adhere strictly to the principles of
ASEPTIC technique in her patient care. • Specimen for culture and sensitivity is collected. Symptomatic
measures are employed for fever, inflammation and pain. IVF and medications are administered as
ordered.

Slide 57: Neurogenic Shock This shock results from loss of sympathetic tone resulting to widespread
vasodilatation. The patient who suffers from neurogenic shock may have warm, dry skin and
BRADYCARDIA!

Slide 58: Neurogenic Shock MEDICAL MANAGEMENT: • This involves restoring sympathetic tone, either
through the stabilization of a spinal cord injury or in anesthesia, proper positioning.

Slide 59: Neurogenic Shock NURSING MANAGEMENT: • The nurse elevates and maintains the head of
the bed at least 30 degrees to prevent neurogenic shock when the patient is receiving spinal or epidural
anesthesia.

Slide 60: Anaphylactic Shock This shock is caused by a severe allergic reaction when a patient who has
already produced antibodies to a foreign substance develops a systemic antigen-antibody reaction

Slide 61: Anaphylactic Shock MEDICAL MANAGEMENT: • Treatment of anaphylactic shock requires
removing the causative antigen, administering medications that restore vascular tone, and providing
emergency support of basic life functions. • EPINEPHRINE is the drug of choice given to reverse the
vasodilatation

Slide 62: Anaphylactic Shock NURSING MANAGEMENT: • It is very important for nurses to assess history
of allergies to foods and medications! • Drugs are administered as ordered and the responses to the drugs
are evaluated.

Slide 63: Triage “trier”- to sort To sort patients in groups based on the severity of their health problem
and the immediacy with which these problems must be addressed

Slide 64: Triage in the E.R. Berner’s Emergent 2. Urgent 4. Non-urgent 6.

Nurse Licensure Examination Reviewer Dennis B. Brosola, RN, MSN

Emergency and Critical Care Nursing National University: College of Nursing
Slide 65: Triage in DISASTER! NATO Immediate 2. Delayed 4. Minimal 6. Expectant 8.

Slide 66: Triage 1. Emergent • Patients have the highest priority • With life-threatening condition 2. Urgent
• Patients with serious health problems • Not life-threatening, MUST be seen in 1 hour 3. Non-urgent •
Episodic illness that can be addressed within 24 hours

Slide 67: Triage Priority Color Conditions Triage in Disaster category 1 RED Immediate Chest wounds,
shock, open fractures, 2-3 burns Delayed 2 YELLOW Stable abdominal wound, eye and CNS injuries
Minimal 3 GREEN Minor burns, minor fractures, minor bleeding Expectant 4 BLACK Unresponsive, high
spinal cord injury

Slide 68: Preparing for terrorism Recognition and Awareness 1. Use of personal protective 2. equipments
Decontamination of contaminants 3.

Slide 69: Biological Weapons ANTHRAX Drug of choice is Ciprofloxacin or Doxycycline SMALLPOX
Supportive

Slide 70: Chemical Weapons Organophosphates • Supportive care • Soap and water • Atropine •
Pralidoxine Cyanide • Sodium nitrite, Amyl Nitrite, Methylene Blue • Sodium thiosulfate •
Hydrocobalamin

Slide 71: CYANIDE POISONING

Slide 73: Radiation Alpha Particles Cannot penetrate skin Causes local damage Beta Particles Moderately
penetrate the skin Can cause skin damage and internal injury if prolonged Gamma Particles Penetrate skin
Can cause serious damage X-ray is an example

Nurse Licensure Examination Reviewer Dennis B. Brosola, RN, MSN