For My Future Self

As I was driving home from an afternoon of running errands, the fuel light came on to alert me that my car would soon need gas. I was tired and hungry, my dog was waiting at home, and I planned to watch a new episode of my favorite show, but I made myself stop at the gas station. The next morning when I started my drive to the hospital, I thanked my “yesterday self” for that act of kindness!Setting goals with your future self in mind is nothing new and is a common strategy. Recent studies have incorporated artificial intelligence and virtual reality into the equation by allowing for a conversation with one’s future self.1,2 This merging of psychology and technology has demonstrated positive effects in substance use disorder recovery, anxiety management, and self-efficacy.Imagine a conversation with your future self. What could you be doing now to benefit that person you will be? With that in mind, perhaps you need to invest in that retirement plan, plant that tree, or schedule that certification examination. Your future self will thank you! Patients with acute ischemic or hemorrhagic stroke are at high risk for acute delirium. Increasing physical activity and adhering to normal routines like sitting in a chair for meals may help mitigate delirium. Benzodiazepines may worsen delirium and should be avoided when possible (B). Although the result of a delirium assessment instrument such as the Confusion Assessment Method for the Intensive Care Unit helps clinicians recognize delirium, performing this assessment alone does not lessen the risk (C). Maintaining a sleep schedule that encourages sleep at night and wakefulness during the day may help mitigate delirium by keeping the patient to a normal routine and ensuring adequate sleep at night (D). Hyperosmolar hyperglycemic state is a complication of diabetes characterized by high blood glucose level and severe dehydration without acidosis or ketone production. It is often associated with an underlying infection. Treatment is focused on administering insulin, restoring fluid balance, and treating the underlying cause. As blood glucose level and fluid status normalize, electrolyte shifts are common and result in hypokalemia. Potassium replacement is a key treatment for hyperosmolar hyperglycemic state. Patients with hyperosmolar hyperglycemic state are not necessarily restricted from oral intake (A), and blood glucose testing is not required more frequently than hourly (C). Diabetic ketoacidosis is characterized by high blood glucose level, acidosis, and ketosis, but ketones are not present in patients with hyperosmolar hyperglycemic state (D). Administration of packed red blood cells and fresh frozen plasma is associated with hypocalcemia due to the citrate content of these products. Trauma patients with hypovolemia and hypothermia are at even higher risk due to the decreased metabolism of citrate by a hypoperfused liver. The Chvostek sign, the twitching of facial muscles upon tapping of the facial nerve, is a sign of hypocalcemia. Serum ionized calcium levels of less than 4.5 mg/dL should be addressed. Hypokalemia is considered when the serum potassium level falls below 3.5 mg/dL, but hypokalemia does not cause muscle twitching (B). Magnesium and phosphorus levels in this patient are within reference ranges (C, D). Extracorporeal membrane oxygenation can be configured in 2 ways: venovenous or venoarterial. Venovenous ECMO provides gas exchange, removing venous blood and returning oxygenated blood to the central veins; the heart then pumps the blood through the circulatory system. Venovenous ECMO, therefore, is indicated only to support patients with respiratory failure. Venoarterial ECMO removes venous blood, provides gas exchange, and also provides mechanical circulatory support, returning the blood to the aorta. Venoarterial ECMO is indicated for patients with cardiac failure (A) and after venoarterial ECMO is applied during a resuscitation event (C). Multiple organ failure is a contraindication for ECMO due to high risk and low odds of survival (D). Care of a patient after submersion injury requires an understanding of the specific lung injury associated with drowning. Fluid entering airways causes loss of surfactant, increased alveolar permeability, and decreased lung compliance. The passage of blood through the lungs without being oxygenated is termed shunting and may lead to noncardiogenic pulmonary edema and hypoxic cardiac arrest. Mechanical ventilation for a minimum of 48 hours is recommended to protect against this cascade. Premature ventilator weaning may cause a return of pulmonary edema (B). Noninvasive mechanical ventilation is inadequate (C). Positive end-expiratory pressure is necessary to overcome alveolar collapse (D). Decreased cardiac output (reference range, 4-8 L/min), decreased cardiac index (reference range, 2.5-4.5 L/min/m2), a pulmonary artery occlusive pressure on the low end of the normal range (reference range, 4-12 mm Hg), and increased SVR (reference range, 900-1400 dyne · s · cm–5) indicate hypovolemic shock. Cardiogenic shock is characterized by low cardiac output, high SVR, and high pressures within the heart (A). Neurogenic shock is characterized by low SVR due to loss of sympathetic tone (B). Although SVR may be high or low in patients with septic shock depending on the phase and compensatory mechanisms, cardiac output is generally in the reference range or increased (D). Cardiac catheterization with percutaneous coronary intervention is indicated for patients with NSTEMI who remain symptomatic despite medical therapy. Opiates may be used to treat pain associated with NSTEMI with careful consideration not to mask pain without treating the cause. Nitroglycerine should be avoided in patients with recent tadalafil use due to the risk of extreme vasodilation and cardiovascular collapse (A, C). β-Blockers may be considered during early hospitalization of patients with NSTEMI but should be avoided if possible signs of heart failure, such as shortness of breath, are present (D). Anaphylaxis is a distributive shock characterized by widespread vasodilation. In a patient with extremely dilated blood vessels, resistance to ejection of blood from the heart is very low (low afterload) and less blood returns to the heart (low preload). Cardiac output is the amount of blood ejected with each heartbeat (stroke volume) multiplied by heart rate. When preload and afterload are very low, stroke volume will also be low. Although an increased heart rate may partially compensate for the low stroke volume, cardiac output cannot be maintained, and this shock state is the result. This telemetry strip demonstrates pacemaker failure to sense. The pacemaker spike is seen immediately after, or sometimes within, a QRS complex, indicating the pacemaker did not sense the intrinsic cardiac function and attempted to generate a paced beat. To find the appropriate sensitivity threshold, gradually turn the sensitivity dial clockwise (to a lower numerical setting) until each QRS complex on the monitor results in a flash of the “sense” indicator light. Reducing this number to half this value provides a margin of safety. However, if the sensitivity is set too low, the pacemaker may sense artifact as a QRS complex and inhibit pacing inappropriately. Increasing milliamps is the appropriate action for pacemaker failure to capture, which would show on telemetry as a pacing spike that is not followed by cardiac activity (A). Increasing the pacemaker rate would result in more frequent pacing spikes but would not change the sensing of intrinsic beats (C). Inappropriate pacemaker firing does not indicate a low battery (D). Shivering is a common complication of targeted temperature management. Subtle signs of shivering may include a slight tremor noted at the jaw or artifact on telemetry. Even this degree of shivering can increase metabolic demand and core temperature and requires treatment (A). Counterwarming is an evidence-based intervention that can reduce shivering by warming the patient’s hands and feet. Administering warmed fluids would increase core temperature, negating the desired effect of temperature management (B). Although benzodiazepines are a treatment option for shivering, counter-warming is an appropriate first nursing intervention (C). 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 [email protected] Sollars, MSN, RN, CCRN, is clinical education specialist and critical care float nurse for Saint Luke’s Health System, Kansas City. She wrote the CCRN questions.POPPASBeth Poppas, MSN, RN, CCRN, PCCN, GERO-BC, NPD-BC, CNECL, CV-BC, is a clinical nurse educator in Inova Schar Heart and Vascular at Inova Fairfax Medical Campus, Falls Church, Virginia. She wrote the CMC questions.