EXAM 1

The weather center has just issued a hurricane warning. What type of disaster warning does the nurse anticipate will be activated? A.Pandemic B.Internal disaster C.External disaster D. Mass casualty event

C. External disaster

What is milrinone?

a positive inotrope it is a smooth muscle relaxant (for severe HF, cardiogenic shock)

EPB for sepsis

measure lactic lactate if >4 do blood cultures before antibiotics meantime give a broad spectrum antibiotic treat hypotension/high lactate with isotonic fluid vasopressors (levophed) maintain glucose under control

Criteria for SIRS (must have 2 or more)

-heart rate greater than 90 beats/minute -body temp < 96.8 F or > 100.9 F -respiratory rate >20 -WBC count > 12,000 or <400

What is a normal lactic acid level?

0.5-1

Tx for heat stroke

02 therapy IV Urinary catheter continuous cooling Benzos if shivering monitor for multi organ dysfunction syndrome

what is transformational leader?

WORKS TO CHANGE A SYSTEM empowers followers to assume responsibility for a common vision, and personal development is a secondary outcome

What is transactional leadership?

WORKS WITHIN A SYSTEM focuses on immediate problems, maintaining the status quo and using rewards to motivate followers

An educator is teaching students about causes of hypovolemic shock. Which of the following manifestations could precipitate hypovolemic shock a. burns b. ascites c. vaccines d. hemorrhage e. insect bites

a,d

what is SBIRT ? screening, brief intervention, and referral?

is an evidence-based approach to delivering early intervention treatment services for persons with substance use disorders, and those at risk of developing a substance use disorder.

in what position do you put the pt in hypovolemic shock?

modified trendelenberg

what is oxygenation/ gas exchange ?

transportation of O2 to the cells and carbon dioxide from the cells

what is preload?

the FILLING pressure/stretch of blood in the ventricles.

What is perfusion ?

the ability for the body to move blood through the vascular system to deliver nutrients and oxygen to the cells, while removing cellular waste

S/S of Heat stroke

•Confusion, delirium, bizarre behavior. •Seizures/ coma *LOW BP/ HIGH HR •Body temp>104(40)Degrees F •HOT, DRY FLUSHED SKIN •Headache/ N&V •absence of sweating is no longer an indicator of heat stroke as patients with heat stroke may continue to sweat. •hallucinations

Crisis definition

•Crisis: a period of disequilibrium overpowering the individual's homeostatic mechanisms

Disaster definition

•Disaster: a catastrophic event that often leads to destruction and loss

•Emergency definition?

•Emergency: a serious situation that arises suddenly and threatens the life or welfare of a person or group of people

Heat Stroke?

•Heat regulation of body fails. Body is no longer able to adjust its temp through sweating. •True medical emergency •Body temp may exceed 104° F (40° C) •High mortality rate without treatment

HYPERTHERMIA

•Occurs at core body temperature <95° F (35° C) •Mild: 90 to 97° F •Moderate: 82 to 90° F •Severe: Below 82° F

Frostbite & RF

•Occurs when body tissue freezes and causes tissue integrity damage •people who smoke, consume alcohol, or have impaired peripheral circulation

Triage category during mass casualty incident (based on chances of survival)

•Red: Emergent needing immediate attention (class I) •Yellow: Can wait short time for care (class II) •Green: Non-urgent or "walking wounded" (class III) •Black: Expected to die or are dead (class IV) - white is for pts who are not injured can go home the same day

S/S of heat exhaustion

•Thirst but this is a late sign of heat exhaustion. •Fatigue •Weakness •Confusion, anxiety, impaired judgement •DRENCHING SWEAT WITH COLD CLAMMY SKIN •Tachycardia •Headache •Dizziness •Syncope •Hyperventilation leading to respiratory alkalosis

degrees of frostbite (least to worse)

•first degree- least severe- edema formation •second degree- large clear to milky fluid filled blisters •third- small blisters that contain dark fluid and affected body part is cool numb or blue •fourth- gangrene

S/S of cardiogenic shock

↑ HR, ↑ RR, ↓ BP, ↓ urinary output, restless, diaphoretic, cool/clammy skin change in mental status

methods of transmission and examples of a disease?

- Contact direct/indirect (C.Diff) HIV - Droplet MRSA, Mumps, Rubella - Airborne Measles, influenza, pertussis, TB, SARS Vector-borne (bugs/animals) anthrax or malaria Environment (contaminated food/water) portal of exit

What are conditions that increase your priority in triage?

-being very young or very old - Alt immunity from drugs or conditions like HIV -multiple medical conditions - pregnancy - ↓LOC - recent foreign travel - abuse/neglect - recent discharge w/ med changes -psychiatric

Tx for heat exhaustion

-move pt to a cool area, feet elevated, supine position - replace fluids/salts - Gatorade, slated tomato juice, 1-2L over2-4hrs, IV fluids -active cooling - if sweating stops then means HEAT STROKE

What are key teaching and safety points associated with weaning a patient off of a ventilator ?

-must be stable w/ minimal metabolic demands - high humidification/close monitoring - comfortable position sitting or semi recumbent - obtain baseline vitals -teach about oral care, suctioning, inhalation/exhalation - need a spontaneous breathing trail (SBT) at least 30 min but not more than 120min monitor for signs of intolerance like spo2 less than 91%, fast/slow breathing, tachycardia, low/high BP, diaphoresis, changes in mental state

Describe the 3 components of Lewins model for change:

. Unfreezing: unfreezing the status quo, creating discontent, assessment for readiness for change Moving: implementing strategies that bring about change, reduce restraining forces, strengthen driving forces. Refreezing: evaluation; reinforce new system policies, and procedures. New status quo.

•The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which of the following would be appropriate to delegate to the nursing assistant? 1) Assist the child to remove outer clothing. 2) Advise the parent to use acetaminophen instead of aspirin. 3) Explain the need for cool fluids. 4) Prepare and administer a tepid bath.

1) Assist the child to remove outer clothing.

cardiogenic shock ?

A state in which not enough oxygen is delivered to the tissues of the body, caused by low output of blood from the heart (HEART PUMPING PROBLEM)

What are the steps of decontamination ?

1st is to remove pts clothing/jewelry/ then rinse the pt in water 2nd is a soap and water wash then rinse Ex: when to use this is for anthrax/ chemical/nuclear attack

what is normal HCO3 level ?

22-26

Fluid management guidelines

3 for 1 rule = 300ml replacement for 100ml of blood lost due blood work (cbc, type & cross) two large gauge IVs 18 or >

•You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? 1. An advanced practice nurse and an experienced LPN/LVN 2. An experienced LPN/LVN and an inexperienced RN 3. An experienced RN and an inexperienced RN 4. An experienced RN and a nursing assistant

3. An experienced RN and an inexperienced RN

what is normal PaCO2?

45-35

what is normal pH range?

7.35 - 7.45

What is primary survey?

A - AIRWAY B- BREATHING C- CIRCULATION D- DISABILITY E- EXPOSURE except when excessively bleeding its ABC *includes checking central pulse, 2 large bore IV catheters, assessing for Neuro disability using AVPU (ALERT,RESPONDS TO VOICE, RESPONDS TO PAIN, UNRESPONSIVE)

As the nurse caring for the patient in the compensatory stage of shock ,what organs does blood flow decrease after the nervous system activates the alpha adrenergic system ? ( SELECT ALL THAT APPLY) a. SKIN b. HEART c. BRAIN d. KIDNEYS e. GASTROINTESTINAL TRACT

A,B,D,E

A basic and widely used triage system has several categories. What does an emergent category for a patient mean? A. Signifying potentially life-threatening injuries or illnesses requiring immediate treatment B. Episodic or minor injury or illness in which treatment may be delayed for several hours without increased morbidity C. Serious illness or injury that is not immediately life threatening D. Process of assessing patients to determine management priorities

A. Signifying potentially life-threatening injuries or illnesses requiring immediate treatment

•A nurse checks emergency medications kept on hand for disaster threats of anthrax. The nurse determines that there are sufficient amounts of which drug? A.Ciprofloxacin (Cipro) B.Penicillin C.Vancomycin Amoxicillin (Amoxil)

A.Ciprofloxacin (Cipro)

what medications help when in shock?

ACE inhibitors - helps lower BP beta blockers - helps reduce BP (block adrenaline) Calcium channel blockers - help decrease blood pressure (prevent calcium which causes contractility more strongly so in return blood vessels relax and open) nitrates - a vasodilator, help widen the blood vessels, in cardiogenic shock only give if BP is over 100 diuretics -used ONLY IN CARDIOGENIC SHOCK bc you are retaining fluid in your heart. inotropes - help with contractility (lessen it or strengthen) vasopressors - they induce vasoconstriction so help increase MAP

what is clinical judgement?

ASSESS, ANALYZE, PLAN &IMPLEMENT, EVAL Decision is made regarding course of action based on data Used to analyze data Helps to determine patient outcome Leads to safe patient outcomes

who report applying dry chemical warmers to the feet. The patient is vigorously rubbing both feet. After the ED physician diagnoses frostbite, the nurse teaches the patient of which further outcome? A. Reduced area of injury B. Possible further tissue injury C. Reduced swelling of the injured area D. Less pain during the rewarming session

B. Possible further tissue injury

What is LVAD (left ventricle assist device)?

Battery powered mechanical pump implanted in the body, it takes blood from lower chamber of the heart and helps pump it to the body.

What are bioterrorism agents ?

Biological- anthrax, plague, smallpox, botulism, viral hemorrhagic fevers Chemical - cyanide, nerve/pulmonary/vesicant agents Nuclear - "dirty bomb", attack on nuclear weapons facilities

•In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? 1. Complete set of vital signs 2. Palpation and auscultation of the abdomen 3. Brief neurologic assessment 4. Initiation of pulse oximetry

Brief neurologic assessment

What is burnout?

Burnout is related to workplace stressors: poor staffing, lack of teamwork, poor management, long hours, workload etc.

Cleansing hands with an alcohol-based hand rub is appropriate in which situation? A. After using the bathroom B. To cleanse visibly soiled or sticky hands C. After handing oral medications to a patient D. After working with a patient who has diarrhea due to Clostridium difficile

C. After handing oral medications to a patient

As the nurse caring for the patient in the late irreversible stage of shock (multi organ failure, trying to preserve the heart & the brain), what should be the expected lab values indicate ? A. Respiratory Alkalosis B. Decreased potassium levels C. Increased blood glucose levels D. Increased ammonia levels

C. Increased blood glucose levels

Compare and contrast CPAP and BIPAP

CPAP- positive pressure delivered throughout entire cycle during spontaneous breathing, used in weaning process *goals are that the collapsed alveoli are used/ lung compliance is optimized/decreased work of breathing BIPAP- pressure support on inspiration/expiration (higher inspiratory + airway pressure & lower expiratory + pressure) works with COPD and will deliver breathes if pt forgets!

What are chemical weapons?

Chemical substances that quickly cause injury and/or death and cause panic and social disruption =Vesicants, nerve, blood, pulmonary

what is compassion fatigue?

Compassion fatigue: getting tired of being sympathetic to patients & their families.

what is controlling in management?

Controlling: the evaluation of staff performance and evaluation of unit goals to ensure identified outcomes are being met. (performance appraisals, quality control).

Identify Prioritization of care principles

Critical, Intermediate, Non urgent. 1. ABC, V(vitals) 2. Mental status changes, acute pain, untreated medical problems, abnormal labs, elimination problems, 3. Long term issues etc

what is Directing/Leading in management ?

Directing/Leading: The leadership role assumed by a manager that influences and motivates staff to perform assigned roles. (human resource management, conflict management, delegating).

An emergency nurse is performing disaster triage following the crash of a 737 jetliner. Which patient does the nurse assign a black tag? A.26-year-old with confusion, yet ambulatory B.40-year-old with an open femur fracture C.54-year-old with facial lacerations D.42-year-old with full-thickness burns to torso and extremities

D.42-year-old with full-thickness burns to torso and extremities

Which patient will the emergency nurse triage for care first? A.7-year-old with protruding ulnar fracture B.19-year-old with nausea and back pain, stating "I have kidney stones" C.43-year-old with weakness and 102° F fever D.54-year-old with upper abdominal and shoulder pain, and profuse sweating

D.54-year-old with upper abdominal and shoulder pain, and profuse sweating

afterload vasodilation = decreased or increased afterload?

DECREASED afterload = decreased workload **goal**

S/S of septic shock

Fever 0ver101, chills decrease urine output alt neuro status resp failure leukocytosis Advancing: DIC increased CO

Hyperdynamic Phase ( WARM phase of shock )

Flushed, warm skin BP low or norm Tachycardia/pnea Fever Increased CO bc trying to increase O2 delivery Pulmonary crackles Oliguria * Altered mental status**

what labs indicate for perfusion?

HGB/HCT ALBUMIN RBC BUN/CREAT

What happens in hypovolemic shock?

HR,BP, Cardiac contractility and cardiac output INCREASE Respiratory rate decreases in order to increase 02 increase in glucose for metabolism increase preload and decrease in urine output

neurogenic shock management

IV stabilize spinal cord injury vasoactive agents atropine if BP comes down too low to reverse it

anaphylactic shock management

IV epinephrine aggressive fluid replacement IV steroids nebulized bronchodilators O2 histamine blocker

S/S of obstructive shock

Increased right sided pressures/symptoms ◦JVD - distention ◦Decreased CO ◦Left sided pressures WNL, right side will go up = INCREASED AFTERLOAD

how to identify sepsis

Increasing serum lactate level, (0.5 - 2.2 mmol/L) bc they are burning fat! normal or low WBC Multi organ dysfunction

what are the trauma center levels and what do they mean?

LEVEL 1 - provides total care for every aspect of injury (prevention to rehabilitation) LEVEL 2 - provides care to majority of injured pts LEVEL 3- stabilizes initial injury than transfers them to a diff hospital LEVEL 4 - provides advanced trauma life support then transfers pt after stabilization

What is the difference between leadership and management

Leadership: ability to inspire others and achieve a desired outcome. Management: is the process of planning, organizing, staffing, directing/leading, and controlling.

After a patient experiences trauma /MI, what is the best way to prevent cardiogenic shock ?

Letting them know they have to change their lifestyle, take meds, exercise !

PPE for contaminated pts ? highest to lowest

Level A - SCBA, vapor tight chemical resistant suit, gloves, boots Level B - high level of resp protection but lesser skin/eye protection, chemical resistant suit Level C - air purified respirator, coverall with splash hood, chemical-resistant gloves, boots Level D - typical work uniform

What is SIRS (systemic inflammatory response syndrome)?

Life threatening organ dysfunction caused by a dysregulated host response to infection

examples of what can cause a cardiogenic shock?

MI cardiomyopathy cardiac injury severe hypertension PE

Hypothermia S/S

MILD = shivering, decrease muscle coordination, impaired cognition, diuresis (excess sweating) MOD= acute confusion, apathy, incoherence, decreased clotting SEVERE= bradycardia, severe hypotension, decrease resp, acid base imbalance, cardiac dysthymias

Why is quality Control so important in healthcare?

Models used to improve outcomes: PDSO: Plan-Do-Study-Act DMAIC: Define issue Measure (collecting data) Analyze Improve current practice Control the future state of interventions

what blood type is the universal donor?

O negative

what is organizing in management ?

Organizing: the organizational structure that determines the lines of authority, channels of communication, and where decisions are made. (determine pt care delivery, working within the structure of the organization).

what is laissez- faire style of leadership?

Permissive, little or no control. Also known as the "hands off approach, gives lots of freedom

what is septic shock?

Presence of sepsis with hypotension despite fluid resuscitation + Presence of tissue perfusion abnormalities

what is planning in management ?

Planning: The decisions regarding what needs to be done, how it will be done, and who is going to do it. (Philosophy, goals, objectives, managing planned change).

A patient undergoing triage reports dizziness. As the nurse collects assessment information, the patient suddenly becomes unconscious. What is the priority nursing action? A. Obtain vital signs. B. Contact the ED physician. C. Evaluate the patient's level of consciousness. D. Position, suction, and administer oxygen, as needed.

Position, suction, and administer oxygen, as needed.

general management of shock

REPLACE FLUIDS (crystalloid and colloid solutions-0.9%NS Lactated Ringers) VASOACTIVE THERAPY (dopamine and dobutamine, Levophed) nutritional support (>300 calories per day) psychological support

how does decreased perfusion affect systemic functioning?

RESP= rapid/shallow crackles tachypnea risk for ARDS (fluid in lungs) hypoxia Cardiovascular= CO decreases weak pulses elevated cardiac enzymes (heart damage indicator) ischemia dysthymias/MI Renal - MAP<65 = poor GFR Elevated BUN/CR urine output <30 cc METABOLIC ACIDOSIS Liver - elevated liver enzymes/ jaundice Neuro- loss of consciousness/mental status changes/ lethargy

what are the 5 rights of clinical reasoning?

Right Cues: data is collected and clustered while looking at the relationship between data collected and the current situation. Right Patient: Identify high risk patients. Right time: timeliness of identifying a status change. Right Action: once a clinical judgement is made, an appropriate intervention should follow. Right Reason: know the why's (putting the puzzle together).

What is an example of a chemical weapon (Nerve agent)?

SARIN this is the most toxic of all the synthetic chemical agents. death within minutes

What are Nerve agents? (chemical weapon)

SARIN, soman organophosphates - causes cholinergic symptoms like loss of consciousness/seizures/apnea/copious secretions/death. -tx: supportive care, atropine, bezo, pralidoxime - decontaminate w/ soap & water or saline for 20 min. Blot do not wipe off!

what is severe sepsis ?

Sepsis + Organ dysfunction

what can cause a neurogenic shock?

Spinal cord injury, spinal cord anesthesia, pain/emotional stress there is blockage in signals and everything slows down and Parasympathetic system takes control ** leads to pooling of blood in vessels

what is staffing in management?

Staffing: The acquisition and management of adequate staff and staffing mix. (recruiting, interviewing, hiring and staff development).

what is sepsis ?

Systemic inflammatory response to documented or suspected infection

Emergency nurses have specialized education, training, experience, and expertise in assessing and identifying patients' health care problems in crisis situations. True or False?

True

What is VAP, and what are key elements to prevent this phenomenon.

Ventilator associated pneumonia HOB 30-40, oral care q 2hrs, use of chlorohexidine swab, suctioning, strict handwashing, drain water form tubing, early extubation, peptic ulcer disease/DVT prophylaxis

What is Ricin ?

a potent toxin (gas) derived from castor beans, recently found in France It affects your upper respiratory system and there is no tx only supportive care S/S of day 1 = cough, fever, dyspnea day 2 -3 = pulmonary edema, resp failure, and death

Identify 5 rights of delegation

a. Right task b. Right circumstances c. Right person d. Right direction or communication e. Right supervision

Identify the 3 step process in Time Management

a. Time to be set aside for planning/establish priorities b. Completion of highest priority task & completion of one task before starting another c. Reprioritization of new task based on new info

what are signs of adequate perfusion?

alert/oriented MAP > 65 urine output >30 pulses WNL warm to touch/tissue color WNL

signs of inadequate oxygenation/ gas exchange perfusion ?

altered mental status respiratory distress respiratory failure hypoxemia anoxia

what are distributive shock types?

anaphylactic septic neurogenic

Initially what is the nurse assessing for in ED? (using the Emergency Severity Index)

assesses only acuity level. if pt is not ESI level 1 or 2 (Resuscitation or Emergent) then the triage nurse will evaluate expected resource needs to help determine a triage level (urgent-3, semi urgent-4, non urgent-5 ESI level)

A nurse educator is providing teaching regarding appropriate interventions for anaphylactic shock. Which of the following should the nurse tell the participants to implement? Select all that apply a.Antibiotics b.Vasodilators c.Antihistamines d.Oxygen based on saturation levels e.Frequent respiratory assessments f.Fluids for volume expansion

b.Vasodilators c.Antihistamines d.Oxygen based on saturation levels e.Frequent respiratory assessments f. Fluids for volume expansion

how do beta blockers affect blood vessels?

beta blockers cause the heart to beat more slowly =less force and helps decrease BP they ALSO help widen veins/arteries to improve blood flow (filling ventricles) DECREASE HR AND INCREASE VENTRICULAR FILLING

what does a SOFA score of 2 or greater mean?

bigger risk of dying from sepsis

what happens in the first stage of shock (initial -compensate)?

blood glucose levels are elevated, blood is blocked away from GI,SKIN,KINDEYS to preserve as much blood flow for the heart and brain. **Lactic acid starts to build up

how is ejection fraction determined and what is the norm?

by an echo and the normal is 60-70%

A nurse is caring for a patient presenting with hypovolemic shock . Which of the following orders should the nurse initiate first ?: a. Administer oxygen at 2 liters per minute b. Obtain two sets of blood cultures before starting IV antibiotics c. Start 1 Liter of Normal saline (0.9) solution at 150 cc per hour d. Draw blood stat for hematology and coagulation measurements

c. Start 1 Liter of Normal saline (0.9) solution at 150 cc per hour - because hypovolemic shock means low volume in the body

•During the primary assessment of a trauma victim, the nurse determines that the patient has a patent airway. The next assessment by the nurse should be to? a. check the patient's level of consciousness. b. examine the patient for any external bleeding. c. observe the patient's respiratory effort. d. palpate for the presence of peripheral pulses.

c. observe the patient's respiratory effort.

what is cardiac workload and how is it different from afterload?

cardiac workload is how hard your body has to work to pump blood to the rest of your body while afterload is the pressure it needs to overcome to push the blood out through the aortic valve

what are examples of Level 1 ESI (resuscitation) ?

cardiac/resp arrest 02 less than 90% critical injured trauma pt with burns/need fluids ASAP stab wound allergic reaction w/ resp distress

shock happens when there is alterations in at least one of these?

cellular response vascular response blood pressure regulation **anything that impairs oxygen delivery to tissues/organs precipitates shock

What to do when administering blood?

check right pt/dose/blood type/2 nurses to check, monitor VS, only have half an hour to hang up the bag

Septic shock?

circulatory shock state resulting from overwhelming infection

anaphylactic shock ?

circulatory shock state resulting from severe allergic reaction producing overwhelming SYSTEMIC VASODILATION

what is neurogenic shock?

combination of both primary and secondary injuries that lead to loss of sympathetic tone and thus unopposed parasympathetic response driven by the vagus nerve. *usually caused by a stroke, everything slows down*

cardiogenic shock management

correct the cause, O2, pain control, hemodynamic monitoring BNP indicator for HF, labs, fluid therapy, mechanical assistive devices goal is to increase O2 to heart & CO, Strengthen contraction decrease workload

Tx for hypovolemic shock

correct the underlying cause initiate fluid replacement and meds to maintain BP and tissue perfusion

s/s of the hypodynamic phase of septic shock?

decreased CO ◦Hypotension ◦Oliguria/anuria ◦Hypothermia ◦Tachycardia ◦Tachypnea ◦Cool, clammy skin ◦Multiple organ failure (DIC)

As the nurse administering IV Norepinephrine ( Levophed ) to the patient, what should the nurse assess for ? a.Low blood pressure b.Increased urinary output c.Metabolic alkalosis Decreased tissue perfusion

decreased tissue perfusion because levophed is used to lower blood pressure.

what happens in the progressive stage of shock? *Life threatening needs action within 1 hour*

diminished vital perfusion (affecting brain and heart now) - dysrhythmias anoxia (brain/body loses 02 supply) ischemia (not enough blood supply) rapid weak pulse low bp pallor/cyanosis anuria (kidneys fail to produce urine) lungs start to fail (CO2 increase, Pulmonary edema)

the goal for an increased preload is to decrease it with what meds?

diuretics to help decrease preload

Level 4 and 5 ESI (semi urgent and non urgent)

express care setting, have trauma related presenting complaint

indications for VAD (ventricular assist devices)?

failure to wean from bypass/ after MI/while waiting a heart transplant

what are requirements for normal oxygenation/gas exchange ?

functional respirator system (inhale/exhale and proper expansion) efficient cellular metabolism increase HGB

what is a complication that can happen in fluid replacement? and what med to give to prevent this

fluid overload so give LASIX inbetween to avoid pulmonary edema.

IF A PT IS EXPERIENCING A RX TO BLOOD WHAT SHOULD THE NURSE DO?

give that IV epi to reverse the anaphylactic to open that airway before giving that 02

What are key teaching and safety points associated with suctioning a patient ?

goal: increase resp rate, work, coughing, hypoxemia adventitious sounds, sterile, pressure 80-120mm hg at suction source, 3 passes/10-15 secs MAX Monitor ECG and spo2

what can cause hypovolemic shock?

hemorrhage, trauma, burns plasma loss, dehydration (v/d) third spacing fluid loss (ascites, hemothorax, pancreatitis)

what is shock?

when compensatory mechanisms fail to maintain perfusion adequately to meet cellular needs of the body.

s/s of neurogenic shock

hypotension, bradycardia, dry skin, temp dysregulation

what does HCO3 help identify?

if it is a metabolic problem

what does PaCO2 help determine?

if its a respiratory problem

what does Ph help indicate?

if its alkalosis (higher) or acidosis (lower than norm)

What is secondary survey?

includes head to toe assessment, identifies other injuries/issues, nurse anticipates to insert gastric tube/urinary cath, prepare for dx studies

increased preload = increased or decreased stroke volume? increased or decreased force of contraction?

increased preload INCREASES stroke volume/force of contraction/myocardial muscle fibers/workload/oxygen demand

who is at risk for septic shock?

infants and elderly people w/ immunosuppression urinary retention invasive procedures/sx alcohol/drug abuse DM burns/trauma

increased pressure (afterload) = increase workload... what does it do to the contraction and CO?

it decreases them (amount of blood being pumped by heart per min)

what is the assistive device IABP (intra aortic balloon pump)?

it increases perfusion to coronary arteries a balloon inserted into femoral artery and placed on heart. it inflates/deflates balloon like cardiac cycle

what does dobutamine do?

it is a inotrope (+) increases vasodilation, contractibility, CO DO NOT USE WITH BETA BLOCKERS S/E: tachycardia/hypertension

what does levophed/norephinephrine do?

it is a vasoconstrictor. it increases bp, CO, afterload

EBP for sepsis

keep blood sugars less than 180 stress ulcer prophylaxis with histamine receptor blockers (pepcid) nutritional support good oral hygiene handwashing positioning HOB 30-45 degrees aggressive mobility strict aseptic technique modified trendelenberg least amount of sedation/no neuro blockers DVT Prophylaxis IV steroids' if not responding to fluids

HEAT EXHAUSTION (hyperthermia)

large amounts of water are lost thru excessive sweating. body can't cool itself down

How many and what are the triage levels?

level 1- resuscitation level 2- emergent level 3- urgent level 4- semi urgent level 5- non urgent

What are examples of vesicants (chemical weapon)?

lewisite, sulfur mustard, nitrogen mustard, phosgene - blistering/burning -do not scrub/use hypochlorite solutions - irrigate eyes -tx : dimercaprol IV or topically

what are signs of inadequate perfusion?

lighted headed/confused loss of sensation decreased organ function ischemic pain cell/tissue necrosis

what diseases are associated with high & low V/Q ratio ?

low - COPD, pulmonary edema , pneumonia high- pulmonary embolism

resp acidosis indicator? alkalosis?

low pH, high PaCO2, normal HCO3 opposite -> high pH, low PaC02, norm HC03

Level 3 ESI (urgent)?

make up 30% of pts in the ED. re assess q 30 min

what happens in anaphylactic shock?

massive vasodilation throughout the whole body early: redness/itchy late: confused, chest pain, swelling, wheezing, respiratory distress

what is the autocratic style of leadership?

my way or the highway

what is a democratic leadership?

n: less control, decision making involves others.

what is the difference between nasophargyneal and oropharyngeal ?

naso does not clear secretions/pt can breathe on their own & conscious oro can't protect airway/they are trying to breathe & are unconscious

what are perfusion components that can cause shock ?

not enough blood volume low cardiac output increased peripheral vasodilation (because it decreases venous return) A MAP of less than 60 (bc it means not enough perfusion to coronary arties/brain/kidneys etc.)

What are the different types of radiation exposure? (nuclear weapon) *3 of them*

o external radiation = all or part of the body is exposed to radiation; decontaminate not necessary & not a med emergency o Contamination= exposure to radioactive gases/liquids/solids. Does require immediate medical management o Incorporation = uptake of the radioactive material INTO the body. catharsis and gastric lavage with chelating agents needed.

people at risk for hyperthermia?

older adults pts with mental health conditions people who work outside homeless people who use drugs outdoor athletes

Radiation Decontamination

outside the hospital cover floor and use strict isolation precautions air ducts and vent sealed waste is double bagged, labeled "radiation waste" protection of staff members first !! measure the radiation that you have been exposed to with a Dosimetry device. (water resistant gown/2 pair of gloves/caps/goggles/masks/booties)

3 p's of tx of cardiogenic shock

pee - make them pee with diuretics pump it with inotropics (milrinone/dobutamine) pull extra volume off the heart with a vasodilator (use nitroglycerin) *can not expose to light!! -nitroprusside (nipride) - dilates, decrease preload/afterload increases myocardial perfusion

Tx for obstructive shock

perfuse peripheral organs remove the obstruction (fluids/dobutamine/dopamine/thrombolytics/sx to remove emboli

Indicator for metabolic acidosis? alkalosis?

ph is LOW & HCO3 are low, PaCO3 is norm opposite for alkalosis - ph & HCO3 are both HIGH, and PaCO3 is normal

Identify 8 leadership traits needed for healthcare today

positive interactions takes initiative energy positive attitude professional development empowerment problem solving and critical thinking skills emphasize interpersonal development/ communication

how do you know if fluid replacement is working?

pt stabilizes on fluids alone pt stabilizes on fluids and deteriorates when rate is decreased *blood products most likely will be needed **VASOPRESSORS CAN ONLY BE FIVEN WITH ADEQUATE VOLUME

what is acute radiation syndrome (ARS)?

radiation sickness from being exposed to high amounts of it in a short period of time. survivors can show no or minimal symptoms or n/v for 24-48hrs, diarrhea and shock, neuro symptoms.

what happens in the non-progressive stage in shock?

renin is trying to hold onto fluid build up of more lactic acid and K+ in blood vessel constriction sympathetic response (Adrenaline, epinephrine)

what is afterload?

resistance left ventricle must overcome to circulate blood by opening the aortic valve.

how to prevent hyperthermia ?

rest freq and take breaks from heat avoid alcohol/caffeine do not overexpose to sun wear appropriate clothes cool baths/showers air conditioning /indoors check on vulnerable adults in a heat wave

sepsis and duration of starting bundles

sepsis- 1 hr - lactic lvl, blood cultures, antibiotics, fluids sepsis/septic shock-6hrs- repeat lactic if first was >2 septic shock- 6hrs- vasopressors

what is worse? sepsis or septic shock?

septic shock

Hyperthermia tx:

shelter from the cold remove wet clothing engage in rewarming DO NOT RUB, avoid dry heat. DO NOT BREAK BLISTERS sterile gauze between fingers/toes monitor for cardiovascular instability, ARDS, acute renal failure, pneumonia

what is obstructive shock?

shock resulting from physical obstruction to blood flow occurs with a decreased cardiac output

what is hypovolemic shock ?

shock state resulting from decreased intravascular volume due to fluid loss

shunt vs deadspace ? (V/Q)

shunt is when perfusion is greater than ventilation deadspace is when perfusion is less than ventilation *SHUNT = poor blood supply + norm vent *DEADSPACE = poor vent + norm blood supply

Anthrax (cutaneous)

standard precautions progression: small papule, ulcer surrounded by vesicles, painless eschar with edema Tx: Cipro, Doxycycline, Penicillin

What is cardiac output? (norm is 6-8L)

stroke volume x heart rate

S&S of nonprogressive stage of shock

tachycardia, anxiety/restlessness thirst cool extremities sbp drops and dnp raises changes in 02 stat

What is triage?

the sorting of patients into priority levels based on illness/severity. They are the gatekeepers

what is hypo dynamic (COLD) phase of septic shock?

there is inadequate fluid resuscitation/compensation. The body cant compensate anymore it has done everything it can.

What happens in the refractory (IRREVERSIBLE) stage in shock?

thrombi formation -DIC *DIC is when you do not have enough blood/volume but the body is trying to clot but they are immature thus bleeding out -Multi organ dysfunction syndrome -slow/shallow respirations non palpable pulse further cell/tissue damage

what to assess/complications with aortic balloon pump?

thrombus formation assess peripheral circulation warning sign: diminished perfusion

what is the goal for hypovolemic shock?

to decrease O2 demand and metabolic requirements increase perfusion & CO TREAT THE UNDERLYING CAUSE THEN RESTORE FLUID/BLOOD (NS or give packed blood cells) MEDS: Inotropes

what is SOFA (sequential organ failure assessment)?

to describe organ dysfunction or failure evaluates 3 Clinical components... Glasgow Coma Scale when it goes below 13, Systolic BP when it goes below 100 and respiratory state is higher than 22

Level 2 ESI (emergent) examples?

unsafe for pt to remain in waiting room, reassess q 15min ex: needle stick, signs of stroke, ectopic preg, pt on chemo with a fever, open fractures, confusion/lethargy/disoriented

what does dopamine do?

vasoconstrictor (when given in big amounts) vasodilator when given in small amounts *used when other therapies are not effective NEVER GIVEN IV PUSH VS q 15min s/e if infiltrated can cause tissue sloughing/necrosis

what drugs would decrease afterload?

vasodilators to decrease afterload.

Describe what is meant by V/Q ratio ?

ventilation = amount of air traveling into alveoli ready for gas exchange Q= perfusion - amount of blood flow to the alveoli

how do you know if its uncompensated or compensated ?

you look at the pH, if it is normal compensated , if it abnormal its uncompensated

bioterrorism definition?

•Bioterrorism: a deliberate release of pathogenic organisms into a community