Study Guide CEN ,Exam Review

COURSE PROSPECTUS AND GOALS….……………………………………………………………………...i
REVIEW OF EXAM..............................................................................................................................................2
SHOCK...................................................................................................................................................................3
CARDIOVASCULAR EMERGENCIES...............................................................................................................9
MEDICAL EMERGENCIES AND COMMUNICABLE DISEASES................................................................19
GASTROINTESTINAL EMERGENCIES..........................................................................................................32
GENITOURINARY, GYNECOLOGIC, AND OBSTETRICAL EMERGENCIES............................................40
NEUROLOGICAL EMERGENCIES..................................................................................................................50
RESPIRATORY EMERGENCIES.......................................................................................................................60
ENVIRONMENT AND TOXICOLOGY EMERGENCIES................................................................................68
PROFESSIONAL ISSUES...................................................................................................................................81
MAXILLOFACIAL AND OCULAR EMERGENCIES......................................................................................89
ORTHOPEDIC AND WOUND EMERGENCIES..............................................................................................98
PSYCHO/SOCIAL EMERGENCIES................................................................................................................107
REFERENCES………………………………………………………………………………………………....112
PRACTICE QUESTIONS……………………………………………………………………………………...114

 At the completion of this section, the learner will be able to:
• Define shock
• Differentiate the signs of compensatory shock from decompensatory shock
• List the three forms of distributive shock
The CEN exam contains nine questions on shock which involve the following topics:
• Cardiogenic shock
• Distributive shock (e.g. anaphylactic, septic, neurogenic shock)
• Hypovolemic
• Obstructive (e.g. pericardial tamponade, tension pneumothorax)
• Shock (not specific)
 Shock (lack of oxygen to the tissues) o Hypovolemic shock – Decreased
cellular perfusion secondary to lack of circulating volume o Cardiogenic
shock – Decreased cellular perfusion secondary to failure of the central pump o
Distributive shock – Decreased cellular perfusion secondary to maldistribution
of the oxygen to the periphery o Obstructive shock – Decreased cellular
perfusion secondary to obstruction of blood into or out of the ventricles (e.g.
pulmonary embolism, pericardial tamponade, tension pneumothorax) 
Obstructive shock
Type of obstruction Treatment
Pregnancy Roll the patient to her side
Tension pneumothorax Chest tube/needle decompression
Cardiac tamponade Pericardiocentesis
Pulmonary embolism Thrombolytics
Aortic aneurysm Surgical intervention
Aortic stenosis Surgical intervention
Excessive positive end expiratory pressure
(PEEP)
Readjust ventilator settings
 Hypovolemic shock o Early (compensatory) shock
Sympathetic nervous system (adrenergic
system)
Parasympathetic nervous system (cholinergic
system)
Alpha
receptors
• Vasoconstriction
• Glucogeonolysis
• Diaphoresis
• Vasodilation
• Gluconeogenesis
• Dry skin
Beta-one
receptors
•  heart rate
•  contractility
•  automaticity
•  heart rate
•  contractility
•  automaticity
Beta-two
receptors
•  respiratory rate
• Bronchodilation
•  respiratory rate
• Bronchoconstriction
Memory Tip – We have ONE heart and Beta-ONE receptors mainly affect the heart
(contractility, automaticity, heart rate, etc.). We have TWO lungs and Beta-TWO
receptors affect mainly the lungs (bronchodilation, respiratory rate, etc.)
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CEN Exam Review - Shock
Presented by: Jeff Solheim RN-BC, MSN, CEN, CFRN, FAEN
Definition:Agonist – Stimulates a system
Antagonist – Diminishes the response of a system
• Late (decompensatory shock
 Inflammatory mediators are released in response to either foreign invasion of tissue or tissue damage. They
have three main courses of action:
• Vasodilation
• Increased capillary permeability
• Increased coagulation
Clinical manifestations of shock
Early (compensatory) shock Late (decompensatory) shock
Blood pressure
Pulse
Respiratory rate
Arterial blood gases
Skin condition
CNS
Urinary output
o Treatment
 Fluid replacement
 Crystalloids
o Isotonic crystalloids given at a 3:1 replacement ratio.
o Generally, a bolus of 1 – 2 liters of crystalloid solution is administered
to a patient with indications of hypovolemic shock.
o Pediatric patients are given boluses at a rate of 20 mL/kg.
• Colloids (given at a 1:1 replacement ratio)
Solution Notes
Dextran (comes
in 40, 70, and 75
molecular weight)
• May cause anaphylaxis
• Increases bleeding times
• Carries a risk of fluid overload
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• How would an alpha-adrenergic agonist affect the blood pressure?
• How would an anticholinergic affect the pulse rate?
• How would a beta-blocker affect the respiratory rate?
Isotonic
solutions
0.9% normal saline (NS)
Lactated Ringers solution (LR)
Hypotonic
solutions
0.45% NS
0.2% NS
Dextrose 5% and water (D5W)
Hypertonic
solutions
Dextrose 5% in NS
Dextrose 10% in NS
Dextrose 10% in water
Dextrose 5% in 0.45 NS
Dextrose 20% in water
CEN Exam Review - Shock
Presented by: Jeff Solheim RN-BC, MSN, CEN, CFRN, FAEN
Hetastarch
• May increase serum amylase levels
• May cause coagulopathies
• Carries a risk of fluid overload
Albumin (5% or
25% solutions
available)
• May cause hypocalcaemia
• Is a human blood product
• Can increase intravascular volume quickly so infuse cautiously and monitor for
indications of fluid overload
Hypertonic saline
(7.5%) with
Dextran 70
• Promotes rapid expansion of blood volume and promotes retention of volume in
the vascular space.
• Frequently used to combat hypovolemia in the face of increased intracranial
pressure.
• Blood Products o ABO Blood types
Woman with Rh antibodies may
pass those on to an Rh positive
fetus during pregnancy causing
hemolytic reactions in the fetus.
Care should be taken to prevent
exposure of woman with Rh
negative blood who may
become pregnant to Rh positive
blood to prevent the
development of Rh antibodies.
O-negative blood is
considered the
“universal
donor”
o Hem
olyti
c
reactions
Early signs Late signs
Anxiety
Restlessness
Nausea and Vomiting
Flushing
Chest/Lumbar Pain
Tachypnea
Tachycardia
Chills
Fever
Cyanosis
Hemoglobinemia
Hemoglobinuria
Heat along the vein receiving
the transfusion
Shock
o Rh compatibility
 Rh positive blood is born with Rh antigens but no Rh
antibodies and should ideally receive Rh positive blood.
 Rh negative individuals are born without Rh antigens and
Rh antibodies. If they receive Rh positive blood, they will
develop Rh antibodies which will cause a transfusion
reaction in future transfusions.
• Types of blood components
Blood component Notes
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Antibodies Antigens
Type A blood B A
Type B Blood A B
Type O blood AB None
Type AB blood None AB
CEN Exam Review - Shock
Presented by: Jeff Solheim RN-BC, MSN, CEN, CFRN, FAEN
Whole blood
•
•
Provides all blood components although clotting factors deteriorate if product is older
than 24 hours.
Must be ABO compatible
• Comes in 500 mL volumes
• Give 20 mL/kg in children
Packed red blood
cells
•
•
•
•
Elevates hemoglobin levels by 1 g/dL and hematocrit by 3% per unit
Best blood product to rapidly elevate oxygen carrying capacity Must
be ABO compatible.
Comes in 250 mL volumes
• Give 10 mL/kg in children
Fresh frozen
plasma
•
•
•
The fluid portion of one unit of human blood that has been frozen solid within six hours
of collection to preserve clotting factors.
Useful for hypovolemia combined with hemorrhage caused by clotting deficiencies
Must be ABO compatible.
• Takes 20 minutes to thaw and must be used within 6 hours of thawing.
Platelets
•
•
Does not need to be ABO compatible
Used for conditions such as hemophilia, von Willebrand disease, hypofibrinogenemia
and factor XIII deficiency.
• Multiple units may be ordered (one unit for every 7 – 10 kg in children)
Cryoprecipitate
•
•
Prepared from plasma and rich in Factor VIII, fibrinogen, von Willebrand factor, and
Factor XIII.
Is frequently given for bleeding disorders such as hemophilia and disseminated
intravascular coagulation.
• Must be ABO compatible
 End points to fluid resuscitation
• Improvement in level of consciousness, condition of
skin and capillary refill
• Decreased pulse and increased blood pressure
• Urinary output o 0.5 mL/kg/hour (adults) o 1 – 2
mL/kg/hour (infants)
• Serum pH and base excess levels returning to normal
ranges
• A stable or decreasing serum lactate level
 Distributive shock
o Neurogenic shock (loss of sympathetic tone)  Causes:
• Spinal cord injuries above T4 – T6
• Brain injury
• Spinal or general anesthesia
• CNS depressants
• Hypoxia
• Lack of glucose or excessive insulin (insulin shock)
• Vasovagal syncope
 Symptoms