Shock

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Exudative phase

-Initial presentation is insidious. May vary depending on the precipitating event -Mild symptoms, if any, for first 1-2 days after injury -Early symptoms may include tachypnea, apprehension, restlessness, accessory muscle use -Chest auscultation: normal or fine crackles -ABG's: Respiratory alkalosis, low PaC02 -CXR: Normal

Antibiotics, Blood, Crystalloid, Lactate Acid, Vasopressors

1 hour sepsis bundle

Class I mild shock

15-20% loss or 750 ml, patient appears normal with slight anxiety and may develop cool extremities

endothelial damage, coagulation dysfunction

2 hallmark signs of sepsis

tachycardia, tachypnea, hyper or hypothermia, high WBC

4 CRITERIA FOR SIRS

Permissive hypercapnia

Allowing CO2 to build up

aspiration

Breathing fluid, food, vomitus, or an object into the lungs

disseminated intravascular coagulation

DIC

clotting factors, platelets, rbc

DIC results from a depletion of

oliguria

Decreased urine output

Epinephrine, fluids , vasopressin, inhaled beta adrenergic agents, Benadryl, H2 blocker

Drugs given in anaphylactic shock

Epinephrine

First line drug of anaphylactic shock

water seal system

If a chest tube becomes disconnected, the immediate priority is to reestablish the _____________

3

In early septic shock, what hemodynamic is present? 1.Elevated Systemic Vascular Resistance 2. Elevated Contractility 3. Elevated Cardiac Output 4. Elevated Preload

Aerobic, anaerobic

In the progressive stage of shock there is a switch from _____ to _____ to produce energy in the cells

inotropic agents

Increase contractility and maintain BP & tissue perfusion

trach tube

Long term intubation Upper airway obstruction due to tumors, swelling, or trauma Facilitate airway clearance due to debilitation (SCI) Humidification is essential

Absolute hypovolemia

Loss of fluid

oropharyngeal airway

Plastic Corner of mouth to angle of jaw Only use in unconscious patient with absent gag

blood products

RBCs Platelets Fresh Frozen Plasma Albumin Cryoprecipitate

Drooling, strider, difficulty breathing, diminished breath sounds

S/s is laryngeal edema and bronchoconstriction

Systemic Inflammatory Response Syndrome

SIRS

sequential organ failure assessment

SOFA

Class iii moderate shock

Which class of shock shows an increase of serum lactate

arterial line

a-line

Cardiac Index

amount of blood pumped out of heart per minute per sq meter of body mass

thrombocytes, fibrinogen

decreased lab values in DIC

hypoxia

deprivation of oxygen supply

100

for chest tube report greater than ______ ml/hr or significant increase

refractory hypoxemia

hallmark sign of ards

low flow, high flow, reservoir

methods of oxygen delivery

Platelets

to treat thrombocytopenia give

Inotropes

dobutamine, dopamine

0.2-0.5 mg 1:1000 im injection

dosage of epi given for mild reaction

1-2 g iv piggyback

dosage of magnesium sulfate given to treat torsades de pointes

24-48 hours

early enteral feedings must be started within

clotting factors

given in response of d dimer

excessive bleeding

when fibrinogen is activated it leads to

2

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop? 1 Hypokalemia 2 Metabolic acidosis 3 Respiratory alkalosis 4 Decreased Pco2 levels

4

A nurse is obtaining an admission history for a client who is scheduled for surgery to repair a ruptured abdominal aneurysm. Which type of shock should the nurse monitor for in this client? 1 Obstructive 2 Neurogenic 3 Cardiogenic 4 Hypovolemic

Class ii moderate shock

15-30% loss or 750-1.5 L , increased anxiety , HR is greater than 100, increased RR, respiratory alkalosis evidenced by low PaCO2, urine output is less than 20-30 mL, pale cool skin & flat jug vein

Indirect cause of ARDS

Lung is injured from a different causeCommon causes: Sepsis, DIC

Multiple Organ Dysfunction Syndrome

MODS

jaundice, increased ammonia, bilirubin and liver enzymes AST, ALT

MODS LIVER EFFECT S/S

metabolism, kupffer cells

how does the liver respond to inflammation

Class iii moderate shock

Which class has an indication of metabolic acidosis decreased renal perfusion, increased BUNZ & creatinine

decreased eryhthropoietin production due to damaged or diseased kidneys

Why is anemia present in MODS?

6.8

if pH is less than it'll result in death

increases, decreases

if resistance increases afterload _______, if resistance decreases afterload _____________

PT , PTT , D DIMER

increased lab values in DIC

vasodilation

relative hypovolemia

12 mg rapid IV

second dose of adenosine given is

decreased afterload problems

septic shock, neurogenic shock, vasodilaion

exudative, fibroproliferative, resolution

stages of ards

Laryngeal Edna & bronchoconstriction

Chest area symptoms of anaphylactic shock

control and comfort

basic component of ventilation

1,3,4

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply. 1 Oliguria 2 Lethargy 3 Irritability 4 Hypotension 5 Slurred speech

2

A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect? 1 Hypokalemia 2 Metabolic acidosis 3 Respiratory alkalosis 4 Decreased carbon dioxide level

airway, breathing, circulation

ABCs

cardiac output

Early in septic shock, the heart is hyperdynamic with a high ___ and low SVR. However, the heart is still performing less than optimally

Hypovolemia, hypoxia, hydrogen, hyper/hypokalemia, hypothermia

H's

Endothelial damage, coagulation dysfunction

Hallmark of septic shock is

causes of DIC

Sepsis (most common) Burns Neoplasms Liver disease Trauma Obstetric patients

1

The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion? 1 Oliguria 2 Crackles 3 Dyspnea 4 Bounding pulse

increases, decreases

for preload if volumes increases stretch __________ & if volume decreases, stretch __________

frozen fresh plasma

give for prolonged pt

7

give red blood cells if hemoglobin is less than

atropine

given when symptomatic bradycardia, toxic poisonings and overdose

90%, 50%

goal is to maintain o2 ABOVE _________ but keep FiO2 less than ____

vasoconstriction, increased SVR,

high doses of epinephrine are for

increases preload problems

hypervolemia, right & left hf, pulmonary hypertension, cardiac tamponade, MI, valvular incompentency

HYPOVOLEMIA

loss of fluid from vascular space

vasodilation, increased HR, decreased SVR

low doses of epinephrine are for

Thrombocytopenia

low platelet count

clotting

low platelets leads to

6

low tidal volume is less than

Tosades de Pointes

magnesium sulfate treats

hypothermia

maintain normothermic temps for adequate function

not recommended

milking or stripping chest tube is _______ because it can increase intrapleural pressures and damage lungs

SvO2

mixed venous oxygen saturation

tunneled cvc

more for chemo patiants surgically placed longterm access, decreased infection risk

D DIMER

most specific indicators of clot degradation

Diuretics

reduce blood volume & preload

cardiac output

volume of blood pumped in one minute

high flow

warmed/humidified, decreased WOB, increased oxygenation (high flow NC)

restlessness

what do patients experience during shock restlessness or lethargy?

venipuncture

puncture of a vein to remove blood, instill a medication, or start an intravenous infusion

acidosis

respiratory _________ is expected in relation to low TV

primary nurse, secondary nurse, iv nurse, airway manager, team leader, recorder, medication nurse

roles of code blue team

initial, compensatory, progressive, refractory

stages of shock

nitric oxide

vasodilator improves oxygenation

nitroglycerin, nitroprusside

vasodilators

nitroglycern, low dose epi

vasodilators

AC, SIMV, PSV

ventilation modes

1,2,3,4

A client who sustained serious burns now has a stress ulcer. Which clinical indicators of shock should the nurse immediately report to the primary healthcare provider? Select all that apply. 1 Weakness 2 Diaphoresis 3 Tachycardia 4 Cold extremities 5 Flushed skin tone

SVR (systemic vascular resistance)

A measure of the amount of resistance which the vascular bed offers to the flow of blood.

1

A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis? 1 Cold, clammy skin 2 Slow, bounding pulse 3 Increased blood pressure 4 Hyperactive bowel sounds

3

A patient in septic shock has labs drawn. The nurse would expect to see all of the following except: 1Increased WBC 2Increased serum lactate levels 3Decreased SVO2 4Increased procalcitonin levels

4

Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early? 1 Urticaria 2 Tachycardia 3 Restlessness 4 Laryngeal edema

sepsis

When Microorganisms invade body and initiate a systemic inflammatory response.

septic shock

When sepsis progresses to circulatory and cellular abnormalities

Class ii moderate shock

Which class of shock is HR is greater than 100

Class ii moderate shock

Which class of shock is Respiratory alkalosis evidenced by low PaCO2

**

a line indications

brachial, radial, femoral

a line is inserted through

fluid loss

absolute hypovolemia

80-100, 7.20

acceptable levels of C02 for permissive hypercapnia is _______ but maintain ph at

increased, leakage

ards results in ________ capillary permeability and __________ of fluid

thrombosis heart

blood clot blocks blood flow in one of the coronary arteries to the heart

110-150 or greater

blood sugar level during sepsis

bad

bubbles in the water seal chamber is

good

bubbles in the water suction chamber is

increased CBC, increase procalcitonin, increased serum lactate, increased blood sugar, increased SVO2

diagnositics for septic shock

increased oxygenation and decreased ICU days

early enteral feeding results is

closed loop communication, clear messages, clear roles and responsibilities, knowing own limitation

effective communication

80-100

normal Pa02

low tissue perfusion, inadequate oxygen delivery to cells, microcirculatory failure

inflammatory mediators and endothelial damage leads to

low flow

8l/min or less (nasal cannula)

acute respiratory distress syndrome

ARDs

Renin, angiotensin II

Activation of ________ produces _______ leading to vasoconstriction & the release of aldosterone & antidiuretic hormone leading to increased sodium and water retention

immediate access, decreased risk of infiltration, reduced need for venipuncture

Advantages of CVAD

4

All of the following are utilized for fluid management in the treatment of hypovolemic shock except: 1 Albumin 2 Crystalloids 3 PRBCs 4 Hypertonic fluids

compensatory stage of shock

Almost immediately, the compensatory stage begins as the body's homeostatic mechanisms attempt to maintain CO, blood pressure, and tissue perfusion

central line associated bloodstream infection

CLABSI

Central venous access device

CVAD

central venous catheter

CVC

Class iv severe shock

Greater than 40% & 2L, tachycardia , hypotension, severe lactic acidosis, absent peripheral pulse & capillary refill , skin is Cushitic , organ failure , patient is confused & agitated or unresponsive

Immunological reaction

IgE mediated ; forked the first time an antigen enters the body second time the antigen enters the body it initials the response of biochemical mediateors that initial a cascade of events that precipitates anaphylactic shock

Decreased, decreased, increased

In anaphylactic shock there is _____ BP, _____ CO, ______ HR

Increased

In anaphylactic shock there is ______ permeability is

Increased

In anaphylactic shock there is _______ gastric secretions

Vasoconstriction

In anaphylactic shock there is coronary

Vasodilation

In anaphylactic shock there is massive

Histamine

In anaphylactic shock what biochemical mediator is released

prone position in ARDs

Promotes shifts from dependent part of lung to undamaged alveoli to be filled with oxygenated blood

1

Sepsis causes all the following changes to the body except: 1.Decreased capillary membrane permeability 2. maldistribution of blood flow to organs/tissues 3. Metabolic changes 4. Coagulation dysfunction

3

The nurse is caring for a client admitted with shock secondary to severe gastrointestinal bleeding. Once the client is stabilized, what intervention should the nurse do next? 1 Monitor the peripheral pulses. 2 Check the level of consciousness. 3 Take a blood sample for laboratory tests. 4 Control the bleeding with a pressure dressing

Crystalloid, colloid, blood products

Types of fluid administration for hypovolemia

Vasodilators

Used for preload and afterload reduction

ventilator associated pneumonia

VAP

Relative hypovolemia

Vasodilation produces an increase in vascular capacitance relative to circulating volume vessels dilate making the body think there is less

control

Ventilator control modes offer more

increases capillary perfusion

benefits of prone position in ARDs

vasopressors, hyper/hypotensive, critically ill

arterial line inidcations

ceases

chest tube assessment: eventually as the air leak resolves and the lung becomes more fully expanded, bubbling _______

autotransfusion

collecting and storing one's own blood to use to replace blood lost during surgery can be frozen up to 10 years

b,d,e,f,h

during anaphylactic shock the mast cells and basophils release a large amount of histamine. what effects does histamine have on the body during anaphylactic shock? select all that apply a. decreased capillary permeability b. vasodilation of vessels c. decreased HR d. shifts of intravascular fluid to interstitial space e. constricts airway f. stimulates contraction of GI smooth muscles g. inhibits the production of gastic secretions h. itching

increased afterload problems

hypothermia, hypovolemia, pulmonary hypertension, ARDS, Pulmonary embolism

decreases preload problems

hypovolemia, vasodilation

hypercapnia

in ARDs there is permissive

decreased , 5

in septic shock there is a _________ PAOP, less than ____

albuterol

inhaled beta andrenergic agents

dobutamine, dopamine

inotropes

Procalcitonin

lab for bacteremia and septicemia

metabolic acidosis

late shock presents with

hypodynamic

later in septic shock the heart becomes

sympathomimetic

vasopressors are what kind of drug

increase oxygenation with decreased Fi02 levels

what is the purpose of peep

Partially compensated

when pH is abnormal and compensating factors are abnormally high/low

neurologic manifestations of MODs

Due to hypoxemia, direct effect of inflammatory mediators, or impaired perfusion Confused, agitated, lethargic, disoriented, comatose Reflective of decreased oxygen/blood flow to the brain

2

A client is considered to be in septic shock when what changes are assessed in the client's labwork? 1 Blood glucose is 70-100 mg/dL 2 An increased serum lactate level 3 An increased neutrophil level 4 A white blood count of 5000 cells/µL

has a short half life

benefits of propofol

quicker neuro checks

benefits of propofol due shirt half life

thrombosis PE

blood clot blocking the main pumonary artery

CLABSI, displacement and leakage, trained individuals for insertion

disadvantages of CVAD

tidaling

if the chest tube is connected to suction, disconnect from wall wall to check for __________

30 degrees, 2

in ARDs HOB ______ AND reposition q____

3.5-5

normal potassium

30 ml/hr

normal urine output

drainage greater than 200 ml, subcutaneous emphysema, respiratory distress

notify MD if the following occur within the first hour

continuous

observe for air leak in water-seal chamber. suspect a system leak when bubbling is _________

2

A client is in cardiogenic shock. Which explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? 1 An irreversible phenomenon 2 A failure of the circulatory pump 3 Usually a fleeting reaction to tissue injury 4 Generally caused by decreased blood volume

increase, decrease

in the exudative phase of ARDs there is a ___________ in RR and a ___________ in tidal volume

1,3,4

A client is diagnosed with gastric cancer, and a subtotal gastrectomy is performed. After surgery the client begins to hemorrhage. What clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. 1 Oliguria 2 Bradypnea 3 Diaphoresis 4 Tachycardia 5 Hypertension

2

A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care? 1 The body initially attempts to compensate by releasing more red blood cells. 2 The body initially attempts to compensate by maintaining peripheral vasoconstriction. 3 The body initially attempts to compensate by decreasing mineralocorticoid production. 4 The body initially attempts to compensate by producing less antidiuretic hormone (ADH)

SCVO2

central venous oxygen saturation

1 hour sepsis bundle

check Lactate level Blood cultures first and then administer broad spectrum antibiotics 30ml/kg crystalloid administration Vasopressors to keep MAP>65

ARDS (acute respiratory distress syndrome)

clinical name of the pulmonary system being affected in mods

low

use _________ tidal volumes (6ml/kg) to ventilate patient

Sodium Bicarbonate

used to increase RR or TV

Fully compensated

when the ph is within normal limits then the patient is

a blockage

with a chest tube no tidaling indicates

normal

with a chest tube tidaling is

0.05-0.1 mg 1:10000 IV

epi given for anaphylactic shock with hypotension

1 mg every 3-5 minutes

epinephrine given during cardiac arrest is

bronchodilates, vasoconstricts, increased myocardial contractility

epinephrine role

0.9 NS, lacted ringer

examples of crystalloids

hypercapnia

excessive carbon dioxide in the blood

diaphoresis

excessive sweating associated with decreased cardiac output

nontunneled cvc

for short term access, for blood, meds TPN placed in subclavian, internal jugular, or femoral vein

Systemic Inflammatory Response Syndrome (SIRS)

generalized inflammation in organs remote from insult

suction control chamber

gentle continous bubbling in the __________ indicates that suction is present and the unit is functioning properly

Direct cause of ARDS

insult to the lung epitheliumCauses: Aspiration, Viral or bacterial pneumonia, pulmonary contusion

20 or larger

iv gauge to administer blood

60-80

normal SVO2 and SCO2

700-1500

normal SVR

70-100

normal blood sugar level

2-5 L/min

normal cardiac index

4-8 l/min

normal cardiac outpute

60-100

normal heart rate

0.5-1

normal lactate

7.35-7.45

normal pH

distal superior vena cava

tip of central venous catheter sits in

chest tubes

to remove air or fluid from pleural and/or medistatinal space

Cryoprecipitate

treats low fibrinogen

trach tube advantages

tubeshorter, wider diameter, and less curved than ETT Resistance of airflow less=breathing easier Easier secretion removal Patient able to eat/talk (passy muir valve)

bleeding and clotting

two clinical manifestations of DIC

1,2,3,4

A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply. 1 Pallor 2 Agitation 3 Tachycardia 4 Narrow pulse pressure 5 Decreased respirations

3

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? 1 Diuresis, irritability, and fever 2 Lethargy, cold skin, and hypertension 3 Thirst, cool skin, and orthostatic hypotension 4 Bounding pulse, restlessness, and slurred speech

comfort

Patient controlled modes offer more

Decreased, less than, less than

In cardiogenic shock there is ______ CO , systolic BP _______ 90, MAP_____ 65

antihistamine, corticosteroid

administer for a mild reaction during a blood transfusion

Mucolytics

help liquify secretions and removal of these secretions

bronchodilators

help relax smooth muscles , epinephrine

sepsis

if SOFA score is greater than 2

Kupffer cells

macrophages in the liver

Vasopressor

Maintains BP when hypotension is severe

2-6

Normal CVP is ______mmHg and is indicative of right sided preload

Inotropic agents, vasopressors, diuretics , vasodilators

Treatment of cardiogenic shock

air leak gauge

an air leak would cause bubbling in the

Benzodiazepines

ativan, drugs that decrease anxiety

3

To prevent septic shock in the hospitalized client, what should the nurse do? 1 Maintain the client in a normothermic state. 2 Administer blood products to replace fluid losses. 3 Use aseptic technique during all invasive procedures. 4 Keep the critically ill client immobilized to reduce metabolic demands.

Remove antigen, reverse effects, promote tissue perfusion

Treatment of anaphylactic shock

crystalloids

What is the preferred choice of fluid resuscitation ?

4

What is the term for shock associated with a ruptured abdominal aneurysm? 1 Vasogenic shock 2 Neurogenic shock 3 Cardiogenic shock 4 Hypovolemic shock

Class iii moderate shock

Which class of shock is bpm greater than 120 and dysthymias

sympathomimetic

agent that mimics the effects of the sympathetic nervous system

tension pneumothorax

air buildup in the pleural space with no way to escape

Norepinephrine

an example of of vasopressor is

bronchodilator

another name for inhaled beta adrenergic agent

0.5 mg IV every 3-5 minutes with 3 mg max dose

atropine doses for bradycardia

Infiltration

bubbling under skin

35-45

normal C02

22-26

normal HCO3

5-12

normal PAOP

20-200

normal PVR

toxins

overdose of medications or street drugs can lead to cardiac arrest

medication

oxygen is classified as a

50%, 24

oxygen toxicity occurs when patient breathers more than _______ for ______ hours

alveoli capillary membrane

oxygen toxicity producesincreased oxygen free radicals that cause damage to ______________

hydrogen ions

pH needs to be normal for organ function

Pressure Support Ventilation (PSV)

patient is in control or respiration and tidal volume

8.0

ph greater than _ it will result in death

Fibrinogen

plasma protein that is converted to fibrin in the clotting process

stretch

preload think __________

Synchronized Intermittent Mandatory Ventilation (SIMV)

preset respiration and tidal volume, can take extra breath at tidal volume of their capability

assist control ventilation (AC)

preset respiration rate and tidal volume, can take extra breath but will be at set tidal volume

PAWP, CVP, CO

pressures taken from Pulmonary artery catheter

oxygenation ventilation, fluid resuscitation, drug therapy, nutritional therapy

priority management in shock

tissue factor

protein that has a role in the initiation of thrombin formation

prepare, wet, dry, ensure, assess

steps for chest tube nursing management

refractory

stubbornly resistant to authority or control

C

the following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. give epinephrine subq b. administer benadryl c. prepare for intubation d. draw blood for cbc

gram positive bacteria

the most common cause of sepsis

contractility

think force

afterload

think force to push against

protein c, protein s, antithrombin

thrombin neutralizer

low

throughout septic shock svr is

normal

tidaling , a fluctuation of the water within the water seal chamber is _____

140-180

tight glycemic control is to maintain blood sugar between

4

A client receiving a blood transfusion that was just initiated reports urticaria and difficulty breathing. The heart rate has increased, the blood pressure is falling, and the client is becoming extremely apprehensive. Which type of shock does the nurse suspect the client is experiencing? 1 Septic shock 2 Cardiogenic shock 3 Neurogenic shock 4 Anaphylactic shock

4

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? 1 Respirations of 10 2 Urine output of 30 mL/hour 3 Lethargy 4 Restlessness

3

A client who is in hypovolemic shock has a hematocrit value of 25%. What does the nurse anticipate that the primary healthcare provider will prescribe? 1 Lactated Ringer solution 2 Serum albumin 3 Blood replacement 4 High molecular dextran

Endotracheal Tube (ETT)

Orotracheal or nasotracheal Short term airway management Indications Maintenance of airway protection Aspiration precautions Positive pressure ventilation Pulmonary toileting High O2 concentrations Upper airway obstruction (secondary to burns, tumor, bleeding) Apnea Respiratory distress

positive end expiratory pressure

PEEP

Coagulation Dysfunction

Due to the release of tissue factor

1

During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism will cause what? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

1

During the progressive stage of shock, anaerobic metabolism occurs. Which complication should the nurse anticipate in this client? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

a

How would a nurse identify a leak in the chest tube and pleural drainage system? •A. There is continuous bubbling in the water-seal chamber •B. There is constant bubbling of water in the suction control chamber •C. Fluid in the water seal chamber fluctuates with the patient's breathing• D. The water levels in the water-seal and suction control chambers are decreased

oxygen levels

Lactate is produced when there is low

Vasopressor

Maintains tissue perfusion until volume is restored

CVAD Indications

Medication administration Blood sampling Blood transfusions Nutritional replacement Renal failure Plasmapheresis Hemodynamic instability

60-70

Normal stroke volume is ______ mL/beat

Tissue eschemia

Occlusion by thrombi=___________=organ failure

ventilator associated pneumonia

Occurs 48-72 hours after intubation Microaspiration of subglottic secretions Artificial airway impairs the defense mechanism of the lung Interventions: Prophylatic antibiotics Early mobilization Oral care q 2 hours (chlorohexidine) Repositioning Q2H Subglottic suctioning HOB 30 degrees Sedation vacations

2

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? 1 Prepare for blood transfusions. 2 Notify the surgeon immediately. 3 Make the client nothing by mouth (NPO). 4 Administer the prescribed preoperative sedative.

Flutter (Heimlich) Valve

One-way valve that opens only when intrathoracic pressure greater than atmospheric pressure Used for emergency transport and for small-to moderate-sized pneumothorax Increased patient mobility Must vent any attached drainage bag

Inhaled beta adrenergic agents

Promote bronchodilation

nasopharyngeal

Rubber Tip of the nose to ear lobe Lubricate tube and insert it midline along floor of the naris into posterior pharynx

Decreased SV, compensatory vasoconstriction, pulmonary edema

Symptoms of cardiogenic shock

Toxins, tamponade, tension pneumothorax, thrombosis heart, thrombosis PE

T's

preload

The amount of stretch in the myocardial fibers at the end of diastole. Represents the volume in the ventricle at the end of diastole

progressive stage of shock

The compensatory mechanisms begin failing to meet tissue metabolic needs, and the shock cycle is perpetuated

1,5

The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply. 1 Rapid pulse 2 Deep respirations 3 Warm, flushed skin 4 Increased blood pressure 5 Decreased urinary output

2,3,4

The nurse is caring for a client who is experiencing cardiogenic shock. Which assessment findings support this diagnosis? Select all that apply. 1 Polyuria 2 Dyspnea 3 Diaphoresis 4 Tachycardia 5 Hypertension

c

You're caring for a patient who is experiencing shock. Which lab result below demonstrates that the patient's cells are using anaerobic metabolism?*• A. Ammonia 18 μ/dL• B. Potassium 4.5 mEq/L• C. Serum Lactate 9 mmol/L• D. Bicarbonate 23 mEq/L

inflammatory mediators

________ in ARDs cause Damage to pulmonary and alveolar endothelium Decreased surfactant Mild pulmonary htn Increased pulmonary capillary permeability Pulmonary edema

never

_________ clamp chest tube

hyperglycemia

_____________ resistant to insulin therapy is frequent in early shock

96 hours

a line dressing should be changed every

hyper/hypokalemia

can lead to dysrhythmias

initial stage of shock

cardiac output (CO) is decreased, and tissue perfusion is threatened.

infection, neurovascular impairment , thrombosis

complications of a line

low fibrinogen

cryoprecipiate is for

steroids

decrease airway inflammation

clamp, patient

if leak persists, briefly _____ the chest tube at the patients chest. if the leak stops, the the air is coming from the _______

blocked, reexpanded, suction

if no tidaling is observed, the drainage system is ______, the lungs are _______, or the system is attached to ______

hypo, decreased, decreased

in ARDs compensation fails leadeing to ____ventilation, _______ CO and _________ tissue perfusion

Prone positioning

in early phase of ARDs increases pulmonary capillary perfusion promotes shift from dependant part of lung to undamaged alveoli to be filled with oxygenated blood

enlarged and fibrotic

in fibroproliferative phase of ARDs alveoli become

8-12

in fluid resuscitation goal is to increase CVP to greater than

SVR

in general shock and hypovolemic there is increased

12,000

in sepsis there is a WBC less than

steroids

in septic shock give __________ if unresponsive to fluids

bounding

in septic shock there is a __________ pulse

CO

in septic shock there is initially increased

general, hypovolemic

in which shocks is there increased SVR

collection chamber, water seal chamber, suction control chamber

3 components of drainage system

preload, afterload, contractility

3 items to affect stroke volume

Class iii moderate shock

30-40% 1.5-2L , decreased BP significant tissue hypoperfusion, increased 120 BPM & dysthymias, increased serum lactate , metabolic acidosis , decreased renal perfusion, oliguria, increased BUN & Creatnine , Patient cold and clammy , decreased capillary refill

1,2,4

A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply. 1 Tachycardia 2 Restlessness 3 Warm, moist skin 4 Decreased urinary output 5 Bradypnea

1

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? 1 Arteriolar constriction occurs. 2 The cardiac workload decreases. 3 Contractility of the heart decreases. 4 The parasympathetic nervous system is triggered.

3

A healthcare provider in the emergency department identifies that a client is in cardiogenic shock. Which type of drug does the nurse anticipate will be prescribed? 1 Loop diuretic 2 Cardiac glycoside 3 Sympathomimetic 4 Alpha-adrenergic blocker

c

An unlicensed assistive personnel (UAP) is taking care of a patient with a chest tube. The nurse should intervene when he/she observes the UAP... •A. Ensuring that the tubing is not kinked •B. Securing the drainage container in an upright position •C. Stripping or milking the chest tube to promote drainage •D. Reminding the patient to cough and deep breathe every 2 hours

Fibroproliferative phase

As lung compliance worsens, fluid accumulates and alveoli collapse, more respiratory difficulty presents Tachypnea, use of accessory muscles Chest auscultation: Fine crackles or rales CXR: Extensive infiltrates (white out or ground glass) As ARDS continues to worsen, refractory hypoxemia occurs with severe dyspnea More respiratory distress leading to intubation/ventilation Severe hypoxemia, metabolic acidosis, tissue hypoxia Altered perfusion/end-organ dysfunction

secondary MODs

Consequence of widespread sustained systemic inflammation (results in dysfunction of organs not involved in initial insult)Ex: Sepsis and SIRS cause AKI, ARDS, and ultimately MODS

Nonimmunological reaction

Direct activation of biochemical mediator msg occurs with severe exposure to cold, heat , ethanol or medication

Primary MODS

Direct consequence of initial insultSmall # of casesInitially causes a localized responseCan lead to secondary MODSEx: AKI, infections, or thermal Injuries

oxygen toxicity symptoms

Dry cough, tracheal irritation, dyspnea, substernal CP, nasal stuffiness sensation, sore throat, and sensation of increased ear pressure

0.2-0.5 mg 1:1000 injection in thigh

Epi given for mild reaction

Dobutamine

Example of inotropic agents

collapsed alveoli

PEEP helps open

peripherally inserted central catheter

PICC

MODS (multiple organ dysfunction syndrome)

Results from progressive physiologic failure of two or more systems

Refractory stage of shock

Shock becomes unresponsive to therapy and is considered irreversible.

Glucagon

This is given if patient isn't responsive to epinephrine

Central venous access device (CVAD)

catherter used for IV therapy, long term or short term, inserted into a large blood vessel

Aldosterone, antidiuretic hormone

cause the kidneys to conserve water and/or salt

pleural space

chest tube assessment: intermittent bubblinh during exhalation, coughing, or sneezing (when the patients intrathoracic pressure is increased) may be observed as long as air is in the ______________

infection, 2 indicators of SIRS, 1 organ dysfunction, SOFA SCORE

diagnosing sepsis

within 1 week of insult, edema not related to HF, oxygenation

diagnosis of ards

respiratory alkalosis

early shock presents with

consumption of essential clotting factors

endothelial damage leads to

72

exudative phase of ARDs is apparent within _________ hours of injury

6 mg rapid IV

first dose of adenosine given is

tamponade

fluid build up in the pericardial sac around the heart characterized by muffled heart sounds, narrow QRS, Rapid HR, decreased pulse, JVD

sepsis with frequent hypotension vasopressors to maintain MAP greater than or equal to 65 Serum lactate is greater than or equal to 2 despite adequate fluid resuscitation

indicators of septic shock

Vasodilators

nitroglycerin, nitroprusside

reservoir

nonrebreather, ventimask

h2 blocker

stress ulcer prophylaxis is treated with

uncontrolled systemic inflammatory response

what uncontrolled response leads to sepsis


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