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Emergency Procedures (Shock, PE, Dehiscence 등) | 마이메르시 MyMerci
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Emergency Procedures (Shock, PE, Dehiscence 등)

NCLEX Review Guide: Fundamentals - Elimination & Emergency Procedures

Elimination Fundamentals

Normal Elimination Patterns

  • Normal urination frequency: 6-8 times per day with 200-400mL per void, indicating adequate hydration and kidney function.
  • Normal bowel movements: Range from 3 times daily to 3 times weekly, with Bristol stool scale types 3-4 being optimal consistency.
  • Factors affecting elimination: Age, medications, diet, mobility, fluid intake, and psychological factors significantly impact both urinary and bowel patterns.

Memory Aid: "FLUID" for Urinary Assessment

  • Frequency - How often?
  • Large amounts or small?
  • Urgency present?
  • Incontinence occurring?
  • Dysuria (painful urination)?

Key Points

  • Always assess baseline elimination patterns before implementing interventions
  • Document intake/output accurately - minimum 30mL/hr urine output indicates adequate kidney perfusion

Emergency Procedures

Shock Management

  • Hypovolemic shock priority: Establish IV access immediately, administer isotonic fluids (Normal Saline or Lactated Ringer's), and monitor for fluid overload signs.
  • Cardiogenic shock interventions: Position patient in semi-Fowler's, administer oxygen, prepare for inotropic medications, and avoid fluid overload.
  • Septic shock recognition: High fever or hypothermia, altered mental status, hypotension despite fluid resuscitation, and elevated lactate levels.

Clinical Scenario: Shock Assessment

Patient presents with BP 80/50, HR 120, cool clammy skin, and decreased urine output. Priority action: Establish large-bore IV access and begin fluid resuscitation while assessing for bleeding sources.

  1. Assess airway, breathing, circulation (ABCs)
  2. Establish IV access with large-bore catheter
  3. Administer oxygen therapy
  4. Begin fluid resuscitation as ordered
  5. Monitor vital signs every 15 minutes
  6. Assess for underlying cause

Pulmonary Embolism (PE)

  • Classic PE triad: Sudden onset dyspnea, chest pain (pleuritic), and hemoptysis - though all three symptoms present in only 20% of cases.
  • High-risk factors: Recent surgery, prolonged immobility, cancer, pregnancy, oral contraceptives, and previous thromboembolism history.
  • Priority interventions: High-flow oxygen, elevate head of bed, prepare for anticoagulation, and position patient on affected side if known.

Memory Aid: "CLOTS" for PE Risk Factors

  • Cancer
  • Long periods of immobility
  • Oral contraceptives/hormones
  • Trauma/surgery
  • Smoking

Wound Dehiscence & Evisceration

  • Dehiscence: Partial or complete separation of wound edges, typically occurs 5-8 days post-operatively when sutures begin to dissolve.
  • Evisceration emergency: Protrusion of internal organs through wound opening - cover with sterile saline-soaked gauze, position patient supine with knees flexed.
  • Risk factors: Obesity, diabetes, malnutrition, infection, increased abdominal pressure from coughing or straining.
  1. Keep patient calm and still
  2. Cover eviscerated organs with sterile saline-soaked gauze
  3. Position patient supine with knees flexed
  4. Do NOT attempt to reinsert organs
  5. Notify surgeon immediately
  6. Prepare for emergency surgery
  7. Monitor vital signs closely

Commonly Confused Points

Condition Key Difference Priority Action
Dehiscence Wound edges separate Apply sterile dressing, notify MD
Evisceration Organs protrude Saline-soaked gauze, emergency surgery
Hypovolemic Shock Fluid loss Fluid replacement
Cardiogenic Shock Heart failure Avoid fluid overload

Quick Check

  • □ Can you identify the difference between dehiscence and evisceration?
  • □ Do you know the priority interventions for each type of shock?
  • □ Can you list the classic signs of pulmonary embolism?
  • □ Do you understand normal vs. abnormal elimination patterns?

Study Tips & Common Pitfalls

Study Strategy

  • Practice prioritization questions - ABCs always come first
  • Remember: Never reinsert eviscerated organs
  • Focus on prevention strategies for high-risk patients

Common Pitfalls

  • Confusing fluid management in different types of shock
  • Forgetting to position patient properly in evisceration
  • Missing early signs of PE in high-risk patients
  • Not recognizing normal variations in elimination patterns

Remember: You've got this! Focus on safety, prioritization, and patient-centered care. Every question you practice brings you closer to becoming an excellent nurse! 🌟

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