Physiological Adaptation

Physiological Adaptation General Information Often, a patient will need some sort of physiological adaptation to preserve and maximize physiological integrity. These questions deal with providing appropriate care for patients with chronic, acute, or life-threatening health conditions and any adaptations required to improve their situations. Body System Alterations A patient’s body undergoes numerous alterations in response to an illness, disease process, intervention, and/or surgery. Recognizing these alterations help to implement proper care to return the patient to a more “normal” state of health. Nurses must explain these adaptations and resultant changes in patient care to help patients understand the reason behind these interventions. Patient Assessment Every patient’s care begins with your assessment of the health and psychological status of the patient. This includes not only alterations due to illness, disease, or interventions/treatments, but also the patient’s ability to cope with his or her health situation and adaptation to an altered (sometimes permanently) state of impairment. Patient assessment may also extend to the patient’s family and external support system as well. Specific Situations The following are some of the more important clinical scenarios in which you will be required to perform these functions: Drainage Tubes Any wound or tube drainage must be closely monitored. Pertinent characteristics of drainage assessment include monitoring for changes in color, consistency, and volume. Common drainage sites include surgical wound drains, respiratory secretions, chest tube drainage, and negative pressure wound therapy. Be familiar with the appropriate care involved in monitoring each. Nurses must be able to perform important interventions with drainage tubes including keeping dressings occlusive, monitoring for leaks or damage to the drainage systems, maintaining the drains (i.e., stripping,emptying, maintaining suction), and changing of equipment. Radiation Therapy Patients undergoing radiation therapy will need to be closely monitored for systemic and localized effects of treatment. Common adverse reactions can include: alopecia, damage to the skin and mucosa, fatigue, immunosuppression, etc. Also be familiar with appropriate lifestyle modifications to discuss with your patient such as proper dietary modifications and sunlight exposure precautions. Prenatal Conditions Understand how to identify potential prenatal complications as well as give appropriate intervention during complications from pregnancy, labor, and/or delivery. Common prenatal complications include constant or excessive bleeding, chemical pregnancy, or molar pregnancy. Complications of later pregnancy, labor, and/or delivery include eclampsia, gestational diabetes, still-birth, birth positioning, and birth trauma. This may also include complications from previous surgical cesarean sections. Nurses should frequently monitor vital signs, especially heart rate and signs of fetal or maternal distress. Infectious Diseases Be familiar with the signs and symptoms of infectious processes. This includes localized findings (pustule, erythema, swelling, etc.) as well as systemic signs (fever, chills, gastrointestinal changes, fatigue, etc.). Understand common incubation periods for various infections, and be able to link a patient’s history of exposure or contact with your clinical findings. Lastly, be familiar with various treatments for infectious processes (bacterial, fungal, viral) as well as specific interventions based on affected body systems (respiratory versus genitourinary versus gastrointestinal, etc.) Invasive procedures Understand the role of the nurse during invasive procedures. Many of these are done at the bedside, so a general, working knowledge is critical. Understand how to identify the patient and verify the order, gather the supplies, and set up for the procedure (i.e., sterile field if necessary), assist and monitor the patient during the procedure, assess and monitor the patient post procedure, and how to properly document the procedure in the medical record. Examples of such procedures include a central line (know patient positioning, preparation, monitoring, etc.); thoracentesis (patient positioning, preparation, specimen care, post-procedural care, etc.); bronchoscopy (patient preparation, sedation/general anesthesia, post-procedure monitoring, etc.), and lumbar puncture (patient preparation, patient positioning, sedation if needed, vital signs, etc.). Phototherapy Be familiar with the uses of phototherapy for both adults and newborns. Phototherapy is most commonly used for physiologic jaundice in neonates. Potential complications of phototherapy include eye damage (all clients should wear protective eye gear while under phototherapy), hyperthermia, and medication interaction (i.e., ibuprofen, diuretics, specific antibiotics). Understand how to implement therapy per the practitioner’s order as well as monitor for therapeutic effectiveness. Hypo and Hyperthermia Understand the risk factors for the development as well as the signs and symptoms of both hypo- and hyperthermia. Hypothermia is defined as a core body temperature less than 95 degrees. Hyperthermia is a core body temperature greater than 99.4 degrees. Nursing interventions to correct these conditions include correcting underlying disorders; hydration and cooling; wet packs for hyperthermia; and warming packs, warming blanket, and warm fluids for hypothermia. Ventilator Use Understand the indications for the use of a ventilator as well as the many potential complications of their use (alveolar overdistension, cardiac complications, oxygen toxicity, hypo/hyperventilation, infection, etc.). While many facilities have specialized respiratory therapists who closely monitor these patients along with the nurse, it is important to have a working knowledge of the care of the patient on a ventilator. Wound Care Be familiar with the signs and symptoms of wound infections including wound temperature changes, erythema, edema, and purulent drainage. Nurses should educate patients on smoking cessation, improved dietary changes, proper wound positioning, adequate hydration, dressing changes, wound care, and early signs of wound deterioration to improve wound healing and early detection of concerns. Understand how to monitor drainage devices in a postoperative patient. Peritoneal Dialysis Be familiar with the indications for and frequency of peritoneal dialysis. Know how to monitor a patient before, during, and after this procedure, and be familiar with common complications and troubleshooting measures used during the treatment to ensure its safety and effectiveness. Nurses should especially monitor for fluid and electrolyte imbalances, consistency and volume of drainage, and patient vital signs. Suctioning Know the proper procedures for performing suctioning of an endotracheal and/or tracheostomy tube, and oral and nasal passages. This also includes preoxygenation prior to and in between suctioning sessions when indicated/necessary. Always remember that when performing deep suction, the nurse should initiate suction while withdrawing the catheter, not during the insertion. Alterations in Body Systems Patients may experience alterations in bodily systems. This includes patients at risk for aspiration, skin breakdown, insufficient vascular perfusion, complications from disease, and any changes from baseline status. Nurses not only monitor their patients for these risks, but also educate the patients and their caregivers how to manage these changes. It is critical for a patient’s recovery to adapt to these alterations whether it is thickening liquids to reduce aspiration after stroke or using a walker for stability after a hip surgery. Ostomy Care Be familiar with the care of patient and patient education for all ostomies including bowel diversion ostomies, tracheal ostomies (tracheostomy), and enteral ostomies (gastrostomy tubes or buttons). Specifically, understand the techniques used to maintain patency of each, prevent complications of each, monitor intake and output (as appropriate) for each and to ensure proper placement and functioning. Stomas of these diversions should be pinkish-red in color without skin excoriation or breakdown. Seizures Understand the difference between primary and secondary seizure disorder as well as the signs and symptoms of the many different types of seizures (absence, tonic, clonic, grand mal, etc.). Be familiar with your responsibilities for patient care during a seizure (patient safety, etc.) and proper postictal care, including proper documentation of the seizure. Pulmonary Care Be familiar with all aspects of pulmonary hygiene care from simple techniques like coughing and deep breathing to more complicated procedures like vibration, percussion, and postural drainage for the removal of respiratory secretions. Understand how to use and teach incentive spirometry. Specifically, understand proper patient positioning during postural drainage, as well as proper technique and location for percussion and vibration. Increased Intracranial Pressure Be familiar with the etiology, signs and symptoms, diagnosis, monitoring and care of patients with increased intracranial pressure. This includes all invasive and non-invasive monitoring (CT, ventriculostomy, etc.). Monitor for changes in consciousness, mental awareness, and physical signs such as pupil size changes and changes in motor skill. Also be familiar with treatments for increased intracranial pressure depending on the underlying cause and severity (pharmacologic management, procedures/interventions, etc.). Post-Operative Care Be familiar with the principles of postoperative care for patients who have received conscious sedation and/or general anesthesia. Understand common postoperative complications (bleeding, pain, infection, etc.) and how to effectively monitor for them and intervene when appropriate to prevent them. Review the procedures for removing sutures and/or staples. Educate patients and their caregivers on any post-operative instructions such as signs of infection, wound disruption, medications, and dressing changes as indicated. Evaluation Nursing care will always include an evaluation of the patient’s response to many of the therapeutic interventions discussed above (surgery, radiation therapy, medications, etc.). Evaluate the patient’s progress toward achieving his or her individual treatment goals. This process typically has five steps: collection of data on the current health status; analysis of the data; comparison of the analyzed data to the patient’s expected outcome; determining the success/failure of specific interventions using critical thinking and professional judgement; and deciding to continue.modify, or discontinue a specific plan of care based on its effectiveness or lack thereof. Patient Education Also incorporate education into patient care to promote the patient’s progress toward his or her health goals. Be mindful of all intrinsic and extrinsic factors that can help or hinder the patient’s progress. For example, the presence of a complicating intrinsic factor, such as diabetes, will require special education and attention to improve the patient’s self-care and implementation of healthy lifestyle choices . Likewise, an extrinsic factor, like a strong family support system, should be maximized to help patients fully return to their optimal state of health. Educating patients on how to maximize their strengths and minimize weaknesses is critical to improving their overall outcome and health. Fluids and Electrolytes Proper nursing care is essential with regard to a patient’s balance of fluid and/or electrolytes. Signs and Symptoms of Imbalance Recognize the signs and symptoms associated with both excess and deficient fluid volume (hypovolemia and hypervolemia) and important electrolytes (sodium, potassium, calcium, magnesium, phosphate, and chloride). Understand the most likely cause of these imbalances given the current health state of the patient as well as the proper management of these conditions. Fluid Hypervolemia is an excess of body fluids (plasma). Underlying causes can vary. Common causative factors include an increased sodium level ( hypernatremia), the inability to clear excessive fluids/supplementation effectively, and organ failure (heart, renal, and/or hepatic). Hypervolemic patients may demonstrate hypertension, dyspnea/shortness of breath, abdominal ascites, peripheral edema, distended jugular veins, and tachycardia. Monitor for bounding pulses and adventitious breath sounds (rales, crackles) throughout the exam. Hypovolemia is the deficit of body fluids and may occur in response to loss via hemorrhage, dehydration, vomiting, and diarrhea. Clinical signs of hypovolemia may include hypovolemic shock, decreased cardiac output, metabolic acidosis, multisystem organ failure, coma and death, if uncorrected. Weak, thready pulses, shallow breath sounds, sunken facial features, and poor skin turgor may be assessed during episodes of hypovolemia. Electrolytes    Sodium: 135–145 mEq/L. Understand the most likely causes and manifestations of excess sodium (hypernatremia) and sodium deficits (hyponatremia). Understand the direct inverse relationship to fluid. Know the likely endocrine disorders that primarily manifest with sodium imbalances (diabetes insipidus, syndrome of inappropriate antidiuretic hormone/SIADH). Symptoms of hypernatremia include thirst, confusion, neuromuscular excitability, seizures, and coma. Symptoms of hyponatremia include nausea/vomiting, headache, confusion, fatigue, restlessness/irritability, muscle weakness, seizures, and coma. Potassium: 3.7–5.2 mEq/L. Understand the most likely causes and manifestations of excess potassium (hyperkalemia) and deficits (hypokalemia). Hypokalemia may occur in the event of diuretics, laxatives, corticosteroids, vomiting/diarrhea, hypomagnesemia, dialysis, insulin overdose, alkalosis, refeeding syndrome, and anorexia. Hyperkalemia may occur in the event of acute/chronic kidney disease, heparin, lithium, congestive heart failure, cirrhosis, sickle cell disease, insulin deficiency, acidosis, digoxin toxicity, and potassium supplementation. Peaked T-waves are often noted with hyperkalemia, whereas decreased T-wave amplitude is characteristic of hypokalemia. Neuromuscular changes are also common in the event of either hypo or hyperkalemia. Calcium: 8.5–10.6 mg/dL. Understand the endocrine feedback system responsible for calcium regulation. Know the most common pathophysiologic causes of calcium excess ( hypercalcemia) and deficits (hypocalcemia) as well as common medications that can trigger calcium imbalance (thiazides, lithium, phenobarbital, corticosteroids, etc.). Symptoms of hypercalcemia include fatigue, depression, confusion, anorexia, nausea, constipation, renal tubular defects, polyuria, short QT interval, and arrhythmias.    Symptoms of hypocalcemia include fatigue, cramping, weakness, paresthesias, altered mental status, hypotension, prolonged QT interval, and arrhythmias. Magnesium: 1.7–2.2 mg/dL. Understand the underlying endocrine and disease processes that commonly affect magnesium levels along with medications that can potentially trigger hypermagnesemia (antacids and laxatives ) as well as hypomagnesemia (diuretics, antibiotics, cisplatin, PPIs , etc.). Symptoms of hypermagnesemia include neuromuscular symptoms, muscle weakness, nausea/vomiting, shortness of breath, cutaneous flushing, hypotension, bradycardia, and hypocalcemia. Symptoms of hypomagnesemia include muscle cramps, hyperreflexia, depression, generalized weakness, anorexia, vomiting, convulsions, apathy, hypertension, ventricular arrhythmia, and death. Phosphate: 0.81–1.45 mmol/L. Be able to identify the disease processes, medications, and endocrine dysfunctions that produce phosphate imbalances. Be able to identify the clinical manifestations of both hypo and hyperphosphatemia. Symptoms of hyperphosphatemia include muscle cramps, numbness around the mouth, bone and joint pain, weak bones, rash, and itchy skin. Symptoms of hypophosphatemia include weakness, trouble breathing, bone fractures, anorexia, tooth decay, and irritability. Chloride: 97–107 mEq/L. Understand the main metabolic causes for low chloride levels or hypochloremia (metabolic alkalosis, respiratory acidosis, hyponatremia, etc.), as well as disease processes that can produce it (cystic fibrosis, etc.). Be able to recognize the clinical signs and symptoms of hypochloremia including fluid loss, dehydration, weakness, fatigue, increased work of breathing, and diarrhea or vomiting. Increased chloride levels, or hyperchloremia, can be the result of numerous disease processes (renal disease, diabetes, hyperparathyroidism, etc.) and through fluid losses (diarrhea, dehydration, diuresis). Be familiar with the common clinical manifestations of hyperchloremia such as fatigue, muscle weakness, excessive thirst, dry mucous membranes, and hypertension l. Pathophysiology Application Caring for a patient with either fluid or electrolyte imbalances or both requires you to carefully consider and anticipate both the pathophysiologic responses to the condition and its treatment. In addition to recognizing the signs and symptoms of these disorders, you must also be aware of the risk factors for their development. This should be an important part of your overall assessment and evaluation. Patient Care Management Care of hypervolemia generally includes fluid/sodium restriction and diuretic medications to clear excess fluid. In hypovolemia, treatment is directed at correction of the underlying cause and is dictated by the patient’s severity. This may range from intravenous fluid supplementation to proper patient positioning (Trendelenburg), plasma expanders, and the administration of blood and blood products. Management of a patient with electrolyte imbalance(s) will rely heavily on correcting the underlying cause (when applicable) along with replacement of depleted electrolytes when indicated and interventions to deplete excesses when applicable. Some of these management scenarios can include emergent interventions, so be familiar with these (cardiac manifestations, seizures, etc.). Evaluation of Patient Response to Treatment As with any treatment given, ongoing patient evaluation will be necessary to ensure patient safety and effectiveness. This will include monitoring for clinical signs and symptoms of normalization of fluids and electrolytes as well as over or undercorrection. Serial lab draws and values will be utilized as well. Certain lifestyle modifications (diet, fluid restriction, medications, etc.) may be necessary for long-term maintenance. Hemodynamics The care of patients who require hemodynamic monitoring is complex. Understand the unique pathophysiologic changes of each patient, as well as the basic aspects of care for patients that require routine and advanced hemodynamic monitoring and intervention. Patient Assessment for Decreased Cardiac Output Understand the physiological principle of: cardiac output (CO) = stroke volume (SV) x heart rate (HR). Normal cardiac output of 4 to 8 L/min is necessary to meet the body’s physiological demands. When this falls short, impairment (mild to severe) will occur. Be familiar with the clinical signs of diminished cardiac output such as diminished peripheral pulses, hypotension, hypoxia, and reduced organ/tissue perfusion (and its sequelae). Cardiac Rhythm Strip Abnormalities Being able to read a cardiac rhythm strip and identify abnormalities is essential for prompt identification and intervention of potentially fatal arrhythmias. Know the proper steps for reading a rhythm strip and the proper timing for all of the waveforms, intervals, and complexes. Understand how to interpret abnormalities in sinus rhythms (tachycardia, bradycardia, etc.), atrial arrhythmias [atrial flutter, atrial fibrillation, supraventricular tachycardia (SVT), and premature atrial contractions/complexes (PACs)], and ventricular arrhythmias [idioventricular rhythm, ventricular tachycardia, agonal rhythm, ventricular fibrillation, Torsades de Pointes, premature ventricular contractions (PVCs), and asystole]. Also be able to recognize the various types of heart block (first, second-type I and II, and third degree as well as bundle branch). Pathophysiology Application Be able to recognize the common physical signs and symptoms of cardiac abnormalities and correlate them with abnormal electrocardiogram (EKG) findings. Also be able to describe the altered path of electrical impulse/cardiac depolarization from normal in each of the above disorders and correlate that with the findings on an EKG (missing P waves, wide QRS complexes, etc.). Understand and be able to distinguish between potentially life-threatening arrhythmias and more benign ones. Patient Care Nursing care of patients undergoing altered hemodynamics is usually specialized, but every nurse must have a basic knowledge of the principles of cardiac care. Providing Patient Strategies Patients with decreased cardiac output will require physical and psychological modifications to cope with their condition. Provide patients with the proper strategies for activity modification, rest, diet, pain modification in addition to ways to deal with cognitive/emotional changes that may result from impaired cardiac function. Also remember that these patients may need proper planning for safety and reduction of risk due to their condition. Interventions Be familiar with emergent intervention protocols for cardiac emergencies (CPR, ACLS protocols, etc.) and be able to initiate them. Also be familiar with the monitoring and maintenance of cardiac pacemakers/defibrillators for patients with chronic cardiac arrhythmias. When caring for patients who have just undergone placement of a pacemaker, be familiar with the common complications of pacemaker placement including insertion site infection, swelling, bleeding, damage to the blood vessels or nerves, and collapsed lung. Managing Care of Patients in Special Circumstances Some cardiac patients will require special care and management depending on their specific care plan and/or condition. Arterial lines— The most common vessels used for surgical placement of arterial lines include the radial and femoral arteries. Indications for arterial lines include need for continuous hemodynamic monitoring, frequent blood sampling, and arterial blood gas sampling. Absolute contraindications to arterial lines include absent pulse, fullthickness burns over the insertion site, inadequate circulation to the extremities, and Raynaud syndrome. Risk versus benefit should be assessed in clients with anticoagulation therapy, atherosclerosis, coagulopathy, infection at the insertion site, partial-thickness burns, previous surgery in the area, and synthetic vascular graft. Pacing device— There are numerous external cardiac pacing devices available to patients. Some familiar types include transcutaneous, transvenous, and epicardial. Indications for external cardiac pacing devices include symptomatic bradycardia, sinus node or AV node dysfunction, and traumatic cardiac injury. Common problems with pacing devices include failure to trigger the appropriate cardiac chamber, underdetection or overdetection of cardiac signals, and unusual EKG findings due to incorrect pacing. Pacing devices are programmed prior to and throughout therapy as indicated and may need routine battery changes and software updates. Review other interventions that may also be indicated in the management of pacing devices. Telemetry— Care of patients on telemetry devices (i.e., continuous cardiac monitoring) may be done solely by the nurse or in conjunction with a specially trained technician. Ultimately, the nurse is responsible for the analysis, interpretation, and intervention(s) provided based on the telemetry reading. Hemodialysis or continuous renal replacement therapy (CRRT) — Understand and be familiar with the various types of venous access that may be used for these patients (arteriovenous shunt, fistula, dialysis catheter, or graft) and the care that they require (anticoagulant therapy, careful fluid balance, central line management, etc.) as well as how to properly monitor a patient before, during, and after therapy. Common complications from hemodialysis and CRRT include hypovolemia, hypotension, hypertension, infection, and electrolyte imbalance. Alteration in hemodynamics, tissue perfusion, and hemostasis— Understand and be able to recognize patients with impaired perfusion of the cerebral, cardiac, and peripheral tissues/organs. Be able to identify the signs and symptoms for each and properly intervene when necessary. Nurses must frequently assess skin turgor, capillary refill and monitor clients’ intake and output. Understand and be able to recognize the risk factors for cerebral, cardiac and peripheral hemostasis, and when it is a desired outcome (i.e., hemorrhage prevention postoperatively). The goal of care of patients with any of these issues is to correct and treat any identifiable, underlying cause and promote good tissue perfusion. Illness Management Nursing care with regard to illness management often involves more than simply “providing care.” Comprehensive management will include the following tasks, which help patients better manage their own illness recovery. Data Reporting Certain pieces of patient data must be reported immediately to the patient’s managing practitioner. This may include adverse reactions and/or complications as discussed in previous review sections. It may also include the patient’s basic and essential needs and/or problems (physical, psychological, safety, etc.), any unexpected outcomes or responses, and any substantial change in status/condition. All patient baseline data should be available and accessible for nurses and healthcare providers. This data helps support the critical thinking skills necessary to evaluate, interpret, and assess the continuous patient changes. Pathophysiology Application A deep understanding of the patient’s pathophysiology is crucial to helping them effectively during illness. This includes understanding all risk factors, etiologies, clinical signs and symptoms, and potential complications of specific conditions. Knowledge of pathophysiology helps to effectively create a care plan that prevents setbacks in a patient’s recovery process. Patient Education A crucial aspect of illness management is the ability to properly educate patients on the nature of their acute or chronic conditions. By doing so, patients gain empowerment and can make informed decisions about their health and care. Proper patient education starts with an analysis of the patient’s needs, deficiencies, and goals. The nurse must then design and implement the proper education activities based on this information. This process may also involve the patient’s family and/or caregivers. Be familiar with the most common components of this type of education. In addition, be aware of implementing a plan for those with a lifelong or terminal condition. This will include education on self-care, modifiable risk factors, and available resources. For clients with acquired immune deficiency syndrome (AIDS), special education needs include reduction of risk potential for infection and spread of infection. Interventions Understand that recovery from an illness involves both intrinsic and extrinsic factors. Some of these factors are innate to the patient (intrinsic) and others are not (extrinsic). Be mindful of both when planning interventions for recovery. Remember that the patient’s wellness comprises many aspects: biological, psychological, environmental, behavioral, sociocultural, and adequacy of healthcare (culturally competent, accessible, etc.) can and will impact recovery. Gastric Lavage Nurses may be responsible for performing gastric lavage if indicated. Common situations that require gastric lavage include drug overdose, poisoning, and gastrointestinal bleeding. Review the process in performing gastric lavage. Continuity of Care Nurses are the most important provider of continuity of care during the course of a patient’s illness or condition. Understand the proper ways to provide seamless, effective, and efficient care that meets your patient’s ongoing and changing needs. This may include education, coordination of care, identification of community resources, ongoing follow-up and continual reassessment and adjustment of the care plan. This also extends to emergency care nurses who must help their patients understand important aspects of their condition, signs of problems, and how to properly follow up with continued care in the community. Ventilation/Oxygenation Patients with impaired ventilation/oxygenation will require special nursing management. Be familiar with many of the indices measured by an arterial blood gas (SaO2, PaO2, PaCO2, pH, and HCO3), as well as components of pulmonary function testing, pulse oximetry, and spirometry. Understand that these patients will and often do require care from a multidisciplinary healthcare team. Evaluation of Treatment As with any other type of nursing care, nurses must provide continuous evaluation of the effectiveness of illness management. Assess each patient’s progress and achievements to ensure they are meeting the expected outcomes as outlined in their planned goals. Medical Emergencies Nurses play an integral part of patient care during a medical emergency. Minimally, knowledge of emergent patient care should include all of the following: Application of Knowledge and Skills When caring for a patient experiencing a medical emergency, nurses must know the most effective way to intervene. This will involve assessment of the patient in a rapid way and minute-to-minute interventions. Be aware that the patient’s status may change rapidly and unpredictably. Pathophysiology Knowledge of the patient’s pathophysiology is paramount in an emergent situation. It is essential to gather thorough details of the patient’s past medical history and current medical status to determine the most appropriate intervention. Conversely, knowing this information can also help to predict the possibility of inadvertently inducing a medical emergency during a treatment or procedure. Nursing Procedures Specific nursing procedures in medical emergencies will depend on the emergency that is being treated. Generally, procedures will be prioritized by ABCs (airway, breathing, and circulation). There are a number of medical conditions that can predispose a patient to a medical emergency that can involve the cardiovascular, respiratory, gastrointestinal, renal, central and peripheral nervous system, musculoskeletal, gynecological (including pregnancy), otorhinolaryngologic, ophthalmic, oral, and dental systems. Psychomotor Skills Nursing psychomotor skills vary during a medical emergency, depending on the patient’s needs. In general, nurses must know how to perform cardiopulmonary resuscitation, assess and clear a blocked airway, and perform the Heimlich maneuver, in order to (minimally) establish an airway and maintain breathing and circulation if clinically indicated. Emergency Care Other aspects of emergency care that nurses should be familiar with are respiratory support (bag-valve-mask, ventilator use, etc.), the use of an automated external defibrillator, advanced cardiac life support protocols and procedures (ACLS), as well as what steps to take in the event of an emergent wound disruption (evisceration and/or dehiscence). Patient Education Even though a medical emergency does not easily lend itself to patient education, nurses must do their best to reassure and inform patients of their current status, planned interventions, and any other critical information throughout the emergency situation. Notification Nurses will often be the first member of the medical team to notify a healthcare provider if a client is experiencing an unexpected response and/or an emergency situation. Unexpected responses may result in vital sign changes, changes in patient status, and reactions or severe side effects of medical therapies. Evaluation With any emergency treatment and/or intervention, nurses are responsible for evaluation and documentation of all events that occurred, including the patient’s response. This includes the establishment of an airway, the restoration of breathing, hemodynamic and peripheral pulses, and the re-establishment of the patient’s physiological stability. Pathophysiology It cannot be overstated how important a nurse’s understanding of pathophysiology is to the proper care and treatment of any patient with either an acute or chronic condition. Identification Nurses will need to be able to correlate all clinical signs, symptoms, diagnostic findings, potential risk factors, complications, and expected outcomes for any pathophysiologic disorder (acute and chronic) for all patients. General Principles The general principles of pathophysiology are:     the four stages of infection the five signs of infection the four phases of bacterial growth the six stages of viral growth Nurses should also be familiar with the phases of the inflammatory process as well as the phases of wound healing. Understand the innate and adaptive immune responses and when each occurs in the disease process. Also understand the principles of active and passive immunity. Response to Therapies For most patients, the response to therapy is predictable and expected. However, there are patients who may and do have unexpected responses to various therapies. Patient Assessment Be aware of the potential risks, complications, and adverse reactions of any intervention, procedure and/or therapy that is given to the patient. Be able to discern between inadvertent/accidental adverse responses (puncture of a vessel during a surgical intervention, retained surgical sponge, etc.) and undesirable yet common adverse events (catheter associated urinary tract infections, nosocomial infections, etc.) and assess patients for both. Clients with concern for altered mental status, stroke, or traumatic brain injury should be monitored for signs of increased intracranial pressure. Hemorrhage may also occur in the event of surgery, postpartum recovery, stroke, and trauma. Complications Be able to recognize the signs and symptoms of expected and unexpected complications. Understand the risk factors that make them more likely and how and when to appropriately intervene when caring for patients that have undergone a particular therapy, intervention, or procedure. This includes emergency care as well. Recovery Complication recovery is very similar to recovery from a primary medical condition. If a complication does occur, understand and be able to provide the appropriate nursing care to promote your patient’s recovery. For example, a nurse would need to provide interventions, care, and assessment for the expected outcome following a catheter associated urinary tract infection (CAUDI) as you would for an infection that is not associated with the use of a urinary catheter.