🚨 Emergency / Critical Care by Nurse Haley
Shock · Sepsis · ACLS/CPR · Defib/Cardioversion · Airway/ARDS · ABG 핵심요약
📖 Table of Contents
🩸 Shock Classification & First Actions
| Type | Typical Findings | First Nursing Actions |
|---|---|---|
| Hypovolemic | Bleeding/dehydration; ↑HR, ↓BP, cool clammy, oliguria | • 2 large-bore IV, rapid isotonic fluids (NS/LR) • Control bleeding, monitor mental status & urine |
| Cardiogenic | MI/HF; pulmonary edema, crackles, ↑JVP | • O₂, cautious fluids, inotropes (as ordered), diuretics • High-Fowler, ECG monitoring |
| Septic | Warm skin → later cool; fever, hypotension, lactate↑ | • Cultures → broad ABX, 30 mL/kg crystalloid • Vasopressor if MAP<65 after fluids |
| Anaphylactic | Urticaria, wheeze, stridor, hypotension | • IM Epinephrine first! O₂, airway 준비 • Antihistamine, steroid, neb bronchodilator |
| Neurogenic | Spinal injury; hypotension with bradycardia, warm dry skin | • Airway & spinal immobilization, fluids • Vasopressor as ordered; atropine for severe bradycardia |
⚠️ NCLEX 핵심포인트:
- Shock 공통: Airway → O₂ → IV access → Fluids → Monitor
- MAP < 65 = 저관류. 소변 < 0.5 mL/kg/hr 주의.
- Shock 공통: Airway → O₂ → IV access → Fluids → Monitor
- MAP < 65 = 저관류. 소변 < 0.5 mL/kg/hr 주의.
🧬 Sepsis Bundle & Lactate
| Time | Bundle Elements | Nursing Notes |
|---|---|---|
| Within 1 hour | Measure lactate; draw cultures; broad ABX; 30 mL/kg crystalloid for hypotension or lactate ≥4 | • Culture 먼저, ABX는 즉시 시작 • 재평가 & lactate 재측정 |
| Persistent hypotension | Start vasopressors to maintain MAP ≥65 (NE 1st-line) | • Arterial line 모니터링 고려 • UO, mentation, skin perfusion 추적 |
💡 Exam Tip: “restless + tachycardia + hypotension” → 초기 쇼크 사인.
Culture는 항생제보다 먼저 채취!
💓 ACLS / CPR & Defib vs Cardioversion
| Topic | Key Points | Nursing Focus |
|---|---|---|
| Adult CPR | Rate 100–120/min; depth 2 in (5 cm); 30:2; minimize pause | • High-quality compressions 우선 • O₂ & monitor 준비, IV/IO access |
| Shockable rhythms | VF / pulseless VT → Defibrillation 즉시 | • Defib → CPR → rhythm check 반복 • Epi q3–5min, Amiodarone 고려 |
| Unstable tachy with pulse | SVT/Afib with RVR, VT with pulse → Synchronized cardioversion | • 동기화 버튼 확인(SYNC) • 진정/진통 준비 |
| Asystole/PEA | Defib 대상 아님; CPR + Epinephrine | • Hs & Ts 원인 교정(저혈량, 저산소, K⁺, 혈전 등) |
⚠️ NCLEX 핵심포인트:
- VF/pVT = Defib, Unstable tachy = Synchronized cardioversion
- Asystole/PEA = Defib 금지, CPR + Epi
- VF/pVT = Defib, Unstable tachy = Synchronized cardioversion
- Asystole/PEA = Defib 금지, CPR + Epi
🫁 Airway, Oxygenation & ARDS
| Condition | Key Findings | Nursing Actions |
|---|---|---|
| Airway compromise | Stridor, use of accessory muscles, silent chest | • Call for help, O₂, prepare advanced airway • Position: head tilt-chin lift (no trauma), jaw thrust (trauma) |
| ARDS | Refractory hypoxemia, bilateral infiltrates | • Low tidal volume, high PEEP(주로 의료진 지시) • Prone positioning 보조, skin & pressure care |
| Vent safety | High pressure alarm = kink/secretions, Low = disconnection | • Suction/비결찰 확인, 회로 연결 상태 즉시 점검 |
💡 Exam Tip: “silent chest”는 더 위험! 즉시 평가·개입.
🧪 ABG Quick Interpretation
| Pattern | ABG | Examples |
|---|---|---|
| Respiratory Acidosis | pH↓, PaCO₂↑, HCO₃⁻ N/↑ | Hypoventilation, COPD exacerbation |
| Respiratory Alkalosis | pH↑, PaCO₂↓ | Hyperventilation, anxiety, pain |
| Metabolic Acidosis | pH↓, HCO₃⁻↓ | DKA, diarrhea, lactic acidosis |
| Metabolic Alkalosis | pH↑, HCO₃⁻↑ | Vomiting, NG suction, diuretics |
⚠️ NCLEX 핵심포인트:
- DKA → metabolic acidosis, compensatory Kussmaul
- Ventilator 문제 시: 먼저 환자(airway/호흡)부터 평가!
- DKA → metabolic acidosis, compensatory Kussmaul
- Ventilator 문제 시: 먼저 환자(airway/호흡)부터 평가!
정리: 오늘의 간호사 Haley
📌 본문 내용은 오늘의 간호사 Haley의 저작물로 무단 복제·배포를 금합니다.
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