Keeping Up and Letting Go

Buckminster Fuller popularized the theory that human knowledge doubles at an accelerated, exponential rate.1 Before 1900, knowledge doubled roughly every 100 years; after World War II, the rate accelerated, doubling every 25 years. With current advancements in artificial intelligence and data generation, some estimates suggest human knowledge may soon double in as little as 12 hours!2 The flip side of the human knowledge algorithmic growth curve is knowledge obsolescence. We often experience this phenomenon in health care, where once-standard medications, diagnostics, therapeutics, tools, and technology quickly become obsolete. As the pace of change accelerates, nurses are increasingly challenged to keep current with evolving clinical evidence, integrate new technologies into practice, and perhaps most importantly, let go of old ways of thinking that no longer align with current evidence. This constant adaptation may seem overwhelming, but when approached with intention, nurses will not just ride the wave of change but will determine where it leads. Certified nurses are especially well equipped to stay current with rapid advancements, given their knowledge base and requirements for continuing education. These will be the leaders who change and shape the future of health care. Fluid resuscitation is the priority in the management of septic shock, especially when the serum lactate level is greater than 4 mmol/L. Antibiotic administration should be delayed until blood culture results are obtained, but antibiotics are not the priority intervention in this case (A). Fluid resuscitation should be optimized before the initiation of vasopressors (C). Corticosteroids are reserved for patients with worsening clinical status, failure of improvement with vasopressors, or multisystem organ failure (D). Patients with ARDS benefit from lung-protective ventilation, with lower tidal volumes (200-300 mm Hg), moderate (100-200 mm Hg), or severe (<100 mm Hg). Ventilator weaning trials are typically initiated when the P/F ratio is greater than 200 mm Hg (C, D), although lower thresholds are sometimes used. This patient is experiencing unstable tachycardia, indicated by the signs of chest pain and diaphoresis. Immediate intervention is required. Synchronized cardioversion is the best immediate intervention for adults with unstable tachycardia. Adenosine 6 mg (A) is indicated for patients with narrow-complex tachycardias, but when a patient is clinically unstable, electrical therapies are warranted. A 12-lead electrocardiogram would be helpful to diagnose the rhythm, but treating the patient is a higher priority (B). Although nitroglycerin may be indicated to treat chest pain in patients with coronary artery disease, immediate cardioversion to treat tachycardia is more likely to improve this patient’s condition (D). Intravenous thrombolytic medication administration is indicated for patients with ischemic stroke symptoms within the designated time window, but other risk factors should be addressed. Blood pressure should be lowered and maintained at less than 185/110 mm Hg. Given this patient’s heart rate, hydralazine would be a better choice than a β-blocker such as labetalol (C). Serum glucose level should be treated if it is less than 50 mg/dL or greater than 400 mg/dL (B). Although an international normalized ratio of 1.4 is elevated, it does not meet the level of contraindication for thrombolytic medication administration, which is 1.7 (D). These blood gas analysis results reflect a partially compensated metabolic acidosis, as would be noted in a patient with diabetic ketoacidosis. Diabetic ketoacidosis causes acidosis with a low bicarbonate level. The depth and rate of respirations increase to correct the acid-base balance, resulting in a Paco2 that is lower than normal. Chronic obstructive pulmonary disease is characterized by a high Paco2 (A). A key sign of acute infectious gastroenteritis is persistent vomiting, which would result in a loss of acid and a metabolic alkalosis (B). A patient with opioid overdose would have acidosis on the blood gas analysis due to hypoventilation and retained carbon dioxide (C). These numbers indicate impaired cardiac pump function. The filling pressures are already high, yet the cardiac index and Svo2 are low (reference ranges: central venous pressure, 2-6 mm Hg; pulmonary artery occlusion pressure, 6-12 mm Hg; cardiac index, 2.5-4.0; and Svo2, 60% to 80%). Therefore, the heart is not ejecting blood effectively despite sufficient preload. These values do not represent hypovolemia (A), in which filling pressures would be low, and they do not fit distributive shock (B), in which systemic vascular resistance is usually low and preload is often normal or low. Although verifying waveforms and leveling is prudent, these values are physiologically coherent, making simple measurement error unlikely (D). For nurses, recognizing this hemodynamic pattern will help prevent unnecessary fluid administration that could worsen pulmonary congestion. The defining feature that distinguishes SCAI stage C (classic cardiogenic shock) from stage B (beginning shock) is the presence of hypoperfusion. Clinical findings such as decreased urine output, cool extremities, altered mental status, and elevated serum lactate level indicate inadequate tissue perfusion and confirm progression to stage C. Although the need for vasoactive medication support (A) or increased preload (B) may occur earlier in the shock continuum, these findings alone do not define stage progression. Similarly, pulmonary edema (D) reflects congestion rather than impaired perfusion and does not independently classify a patient’s shock as stage C. Nurses play a key role in identifying hypoperfusion early to prompt timely escalation of care. Norepinephrine is generally the first vasopressor nurses anticipate starting in patients with cardiogenic shock due to its α-adrenergic effects. These effects increase vascular tone and blood pressure with less β1 receptor stimulation and fewer resultant tachyarrhythmias compared with dopamine or epinephrine. Dopamine (A) is much more likely to trigger tachyarrhythmias, and epinephrine (B) can increase serum lactate levels and myocardial oxygen demand. Phenylephrine (C) increases afterload, which can impede cardiac output. Understanding why norepinephrine is preferred helps nurses anticipate therapy and recognize when medication choices do not match the patient’s physiology. This hemodynamic pattern should immediately raise concern for cardiac tamponade. After cardiac surgery, a sudden decrease in blood pressure with narrowing pulse pressure and increased preload (central venous pressure) suggests impaired ventricular filling due to cardiac compression. This scenario is different from acute right ventricular failure (A), in which the central venous pressure is high but the pulmonary artery occlusion pressure is lower. Hypovolemia (B) would cause low preload. Vasoplegic syndrome (C) presents with low systemic vascular resistance and warm extremities, not obstructive physiology. Nurses are often the first to see these changes, and rapid recognition can be lifesaving. Heparin-induced thrombocytopenia is a life-threatening condition in which antibodies are formed against the heparin–platelet factor 4 complex, which is activated when platelets are exposed to heparin. This condition leads to thrombocytopenia and a high risk for thrombosis. Immediate management includes discontinuing all heparin administration and initiating a nonheparin anticoagulant such as bivalirudin. Enoxaparin sodium is a low-molecular-weight heparin, which would continue exposing the patient to heparin (A). Although the platelet count is low due to immune-mediated platelet consumption, platelet activation creates a paradoxically high risk for thrombosis, requiring immediate initiation of nonheparin anticoagulation (B). Protamine sulfate reverses heparin in patients with severe bleeding or overdose but is not indicated for patients with heparin-induced thrombocytopenia (C). Early recognition of possible heparin-induced thrombocytopenia and removal of heparin-containing infusions, flushes, and coated catheters are key nursing actions in the care of these patients. AACN Certification Corporation publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN certification examination handbook. The contributor of each question written for this column has listed the source used in developing each item. Clinical practice should be based on primary sources of evidence when possible; this column will also include secondary sources to help nurses become aware of available resources for certification review.EBBERTSMarci Ebberts, MSN, APRN, FNP-C, CCRN, is the department editor. Marci is program director of nursing research at BJC West, Saint Luke’s, Kansas City, Missouri, and a practicing occupational health nurse practitioner. She welcomes feedback from readers and practice questions from potential contributors at ebberts.aprn@gmail.com.SUMNERJacob Sumner, BSN, RN, CCRN, is a nurse in the cardiothoracic intensive care unit at NKC Health, North Kansas City, Missouri. Jacob wrote the CCRN review questions.STONEBrittany Stone, DNP, AGACNP-BC, is a critical care nurse practitioner at Missouri Baptist Medical Center, St Louis, Missouri. Brittany wrote the CSC review questions.