NUR 4420 Final Exam (Week 10)

Management of septic shock

"Fill the tank & constrict vessels" ---> IV fluids (0.9% NaCl, LR) ---> Vasopressor (Dopamine) Decrease the cause: • C&S • Remove catheters & Drains • Debride wounds/drain abscesses • Amputate gangrenous extremity • Abx (broad spectrum like ahminoglycosides and cephalosporins) • Anti-fungals (Diflucan)

Nursing interventions to establish adequate oxygenation w/ MODS

***Want to inc perfusion bc all of these problems are from dec perfusion Maintain adequate cardiac function Maintain adequate Hgb levels Suction PRN Use sedative/paralytics agents Use PEEP, keep PaO2 >80 mmHg ---> PEEP keeps alveoli open but dec CO Provide pulmonary hygiene

What neuro changes are seen w/ MODS?

*CHANGE IN LOC* ---> First thing we see Cerebral ischemia causes a stroke risk because of the micro emboli in the system Cerebral hemorrhage Cerebral vasodilation causes IICP, possible aneurysm *Dec CPP*

Hematological effects w/ MODS

*Consumption of hematologic & clotting factors which will CAUSE DIC* ---> Pt will bleed from everywhere Dec WBCs, RBCs, Plts

What are the priority nursing problems of burns

*Impaired gas exchange* *Impaired tissue perfusion* *Risk for infection* ---> WBC may fall <5 within 48 hrs after injury & <2 if using SSD *High risk for self-care deficit* ---> Burns on hands & feet could mean permanent disability *Impaired skin integrity*

Hypothermia & Trauma

2/3 of all bleeding trauma pt arrive in the ED w/ a core temp <96.8º (36ºC) Pt is losing blood which is an insulator & hold energy

Parkland formula

4 mL x TBSA burned x Weight in kg This is the amount of fluid you need for 24 hours Give 1/2 of that fluid in the first 8 hrs & the next 1/2 in the following 16

Autoregulation of the body tries to keep the MAP ___ to ____

60-130 mmHg

Staph scalded skin syndrome (SSSS)

77-94% are drug-induced (sulfonamides, anticonvulsants, NSAIDS, analgesics) S&S (2-4 days before sloughing of skin) ---> Malaise ---> Sore throat ---> Fever ---> Rhinitis ---> Anorexia ---> Coughing ---> Skin lesions (pruritus, erythema, blisters) Epidermis separates from dermis w/ mild pressure ---> +Niklolsky's (Bright red partial thickness wound) ---> Esophagitis ---> Inflamed genitalia

Ethical/religious concerns w/ organ donation

7th day adventists: - Individual & family may receive or donate organs Muslims: - Can't receive stored organs Jehovah's witness: - Transplant must be completely drained of blood before receiving it

Candidate requirements for heart transplant

<65 yr AHA class III IV CHF Life expectancy < 12 mo

Mafenide acetate cream

ADVANTAGE: Penetrates through eschar & is bacteriostatic DISADVANTAGE: Uncomfortable/burning sensation ---> Requires 2-3 dressing/day bc it is rapidly absorbed ---> Can cause hyperventilation & metabolic acidosis

A patient is at risk for kidney injuries after a trauma. Why?

AKI --> D/t hypovolemia from injury ---> Prevent w/ fluid resuscitation Rhabdomyolysis & myoglobinuria ---> Caused by muscle & crush injuries which compromises blood flow ---> Causes ischemia & muscle breakdown which lodges in the glomerulus

When assessing a pt's neuro status, what should a nurse look for?

AVPU ---> A= Alert ---> V = Response to voice ---> P = Response to pain ---> U = Unresponsive GCS

Criteria for brain death

Absence of spontaneous movement Flaccid extremities No longer have posturing Have been in coma >24 hrs No spontaneous breathing No brainstem reflexes ---> No corneal reflexes ---> No gag reflex ---> No doll's eyes ---> No vestibular response w/ cold caloric test No blood flow to brain w/ arteriography No brain waves when using EEG

chronic rejection

After 3 mo time period Inc ischemia to organ transplant that dev over time Tx = another transplant

Multi-system Organ Dysfunction (MODS)

Also called systemic inflammatory response syndrome (SIRS) Critical illness that progressively involves 2 or more systems

Assessment findings for neuro w/ MODS

Altered LOC H/A Hepatic encephalopathy Hypothermia or hyperthermia ---> We put them in hypothermic conditions for MI & CVA to dec metabolic demand & then slowly warm them back up after *24 hr* GCS < 6 ---> A score of <7 means it will be difficult to get pt back to normal ICP > 15 mmHg Respiratory depression

An open pneumothorax has the same S&S as a closed except that it has....

An obvious injury on the affected side A "sucking" sound on inspiration on the affected side SQ emphysema in the upper chest & neck Signs of reduced venous return

After the fluid shift w/ burns, the patient is at risk for what?

Anemia d/t loss of RBCs Neg Nitrogen balance d/t tissue destruction, protein loss, & stress response Weight loss d/t diuresis, catabolism, loss of water from wound Stress ulcers d/t insult

How can a nurse stop the burning process?

Apply cool water to burn or hold burned area under cool running water ---> Do NOT disturb blisters that are formed ---> Do NOT apply anything to wound Cover w/ clean cloth Remove burned clothing & jewelry If it is a small burn, you can give PO fluids ---> If it is large, make pt NPO to dec peristalsis & prevent vomiting & aspiration If pt is on fire, smother the fire ---> Place pt in horizontal position ---> Roll victim in blanket or similar object & avoid covering head

RULE OF NINES (KNOW)

Arm = 9% each (front & back) ---> 4.5 % for just front OR back Head & neck: 9% for total burn ---> 4.5% for just front OR back of head Leg: 18% for total burn ---> 9% for just front OR back of leg Perineum: 1% for total burn Anterior trunk: 18% Posterior trunk: 18%

How can a nurse assess for adequate fluid resuscitation?

Assess HR: •• If HR <120, fluid is adequate •• If HR >120, more fluid is needed Monitor hourly I&O Give Mannitol If perfusion is inadequate, give dopamine or Dobutrex

ER management of burns

Assess peripheral circulation ---> Full-thickness circumferential burns w/ edema compromise blood flow ---> May need escharotomy Cyanosis, dec capillary refill, deep tissue pain, & paresthesia occur If there is a loss of pulse in the Palmar arch, upper extremity, and posterior tibial then *incision must be made thru eschar & superficial fascia* Assess ventilation Put in 2 IV access sites ---> 1 for fluid, 1 for blood components

Nursing management for pt w/ heart transplant

Auscultate heart & breath sounds Monitor pedal pulses Assess for JVD Monitor CBC, renal/liver function

What is the permanent graft that is used for burn pt?

Autograft: Pt's own skin is removed & applied to burn

What is the thing healthcare providers are must concerned about w/ burn patients?

BSA of burn & how quickly we can get fluids in them (fluid resuscitation)

Silvadene (silver sulfadiazine/SSD)

Bacteriostatic agent against gram - & + bacteria ---> Alters DNA & Cell metabolism ADVANTAGES: • Painless application • Effective against yeast • Non-toxic DISADVANTAGES: • Poor eschar penetration • Transient neutropenia • Forms proteinaceous gel on wound surface that is painful to remove • Dec granulocyte formation

When removing clothing for trauma pt that was involved in a MVA, gun shot, etc. what 2 things should a nurse consider?

Be caution to prevent hypothermia Preserve forensic evidence ---> Be careful of hidden drugs ---> Always wear gloves

Diuretic stage of burns

Begins 48-72 hrs after burn injury Capillary membrane integrity returns & edema shifts back into IV spaces

Hypovolemic stage of burns

Begins at time of burn through 48-72 hrs after ---> *First 24 hr is critical for fluid resuscitation* There is a rapid shift of fluid from the vascular compartment to the interstitial so the person will look edematous Vasodilation w/ inc capillary permeability occurs around burn site ---> *Pt will feel warm to the touch* THE GREATER THE % OF THE INJURY, THE GREATER THE FLUID LOSS

GI related lab values that are changes w/ MODS

Bilirubin >2.9 mg/dl LDH & SGOT > 50% normal Albumin <2.8 g/dl Hyperglycemia that dev into hypo

A patient presents in the ICU w/ MODS. The nurse knows what symptoms signify dysfunction of the GI system?

Bowels start to die because dec blood flow to the intestines ---> GI system is one of the first systems to lose blood supply Pt has gastric ulceration (*Largely seen w/ MODS*) ---> Give PPI, gastric reducing agents Splanchnic blood flow impairment Inc bacterial load resulting in systemic bacterial translocation ---> *More bacterial d/t ischemia* ---> H. pylori is most common

Sulfamylon (mafenide acetate)

Broad spectrum agent that targets both gram -&+ bacteria Also kills pseudomonas & clostridium BENEFITS: • Penetrates eschar & diffuses rapidly into burn & underlying tissue • Effect in deep flame/electrical/infected wounds DISADVANTAGES: • Painful for 20-30 mins after application • Possible metabolic acidosis from hyperventilation • Inhibits wound healing • Hypersensitivity

CPK & trauma

CPK is inc when muscles start to die Ex: Rhabdomyolysis Normal = 200, should be <210

ARDS & trauma

Can be caused by direct injury to the lungs ---> Aspiration, inhalation injury, pulmonary contusion Can also be d/t indirect injury to lungs ---> Sepsis, massive transfusion, fat emboli *Usually occurs 24-72 hrs after injury/trauma*

Tissue donor criteria

Can be up to 80 yrs Can be any hospital or ER death Heart may be asystole but donation must be made within 4 hrs Client must be free from systemic infectious disease ---> No SIRS/MODS Can have no autoimmune disease

Causes of cardiogenic shock

Cardiac related: • Acute MI ---> LV dyfx >40%, shock occurs within 48 hrs • Papillary muscle dysfx/rupture • Interventricular septal defect Non-cardiac related • Hypoxemia • Acidosis • Hypoglycemia • Hypocalcemia • PE • Tension pneumothorax • Cardiac tamponade

Thermal burn

Caused by exposure or contact w/ flame, hot liquids, semi-liquids, semi-solids, or hot objects Different types: • Heat/cold • Chemical • Electrical • Radiation • Exfoliation skin syndromes

Heat/cold burns

Caused by flames, scalding, contact w/ hot substances, cigarettes, road tattoo Most common cause of a burn in children

Distributive shock

Caused by maldistribution of blood flow ---> Intravascular volume & heart's functions are normal but blood is not reaching tissues 3 types: • Septic • Anaphylactic • Neurogenic

What does MODS do to the renal system?

Causes endothelial damage d/t decreased perfusion ---> *Will cause prerenal & intrarenal failure* Renal vasoconstriction Microemboli results in renal ischemia & an inc risk of MI Renal interstitial edema

Hypotonic solutions are given to patients w/....

Cellular dehydration

A patient from a MVA has renal trauma. What are the S&S of this?

Change inc LOC Impaired RAAS so BP dec ---> MAP drops Hematuria Blood at urinary meatus Dec UO Grey Turner & Cullen's sign Acidotic state d/t change in BS ---> Causes Kussmaul's RR ---> Diaphoresis Tachycardia CVA tenderness Enlarged mass surrounding kidney

3 stages of shock

Compensatory stage Progressieve stage Refractory stage

Drugs given after transplant

Corticosteroids (Prednisone) Cyclosporin A Imuran Immunoglobulins Cytoxan Methotrexate

Silver nitrate

Cream, probably most common agent Effective against wide spectrum of pathogens (including fungal) Bacteriostatic against major burn flora including pseudomonas & staph ADVANTAGES: • Great dec evaporation loss • Does not interfere w/ wound healing DISADVANTAGES • Limited joint motion • Equipment & environment staining • Poor eschar penetration • Makes wound assessment difficult d/t staining • Hypotonicity pulls electrolytes from wound which *depletes Na, K+, Cl-, & Mg+* ---> BIGGEST problem

What should be given to help treat hypovolemic shock?

Crystalloids ---> 0.9% NaCl or LR ---> Give 3x the volume needed ---> Causes hemodilution w/ dec Hgb & O2 delivery Colloids ---> Dec risk for pulmonary edema & maintains oncotic pressure ---> Works better than crystalloids for volume expander BUT it is expensive & alters coagulation Blood products ---> Pt's own blood (autologous) ---> PRBCs + crystalloids = inc O2 carrying capacity & dec risk for fluid overload

S&S of late septic shock

Dec CO Severe hypotension w/ a weak, rapid pulse Hypothermia, cold, clammy Mottled appearance MODS DIC may come into play

S&S of cardiogenic shock

Dec CO Hypotension Dec CO LV EF <30% Change in LOC Dec peripheral pulses Cool, clammy skin NVD Peripheral edema Pulmonary edema Inc CVP & PAP Inc SVR d/t vasoconstriction CI < 1.8

S&S of renal failure w/ MODS

Dec GFR ---> Puts us in ARF (Pt oliguric then diuretic) Oliguria, anuria, or polyuria Electrolyte imbalance

Hemodynamic changes w/ hypovolemic shock

Dec SV Dec CO Dec CI Dec PAP Dec O2 consumption Inc SVR

How do we treat malignancy in post-transplant pt?

Dec amount of immunosuppressant pt has Give chemo & radiation therapy Surgical resection

Causes of shock

Dec fluid volume ---> Hypovolemic shock which may dev into cardiogenic Poor pumping ability of the heart ---> Cardiogenic Impaired distribution w/ inc peripheral vasodilation ---> Septic

2 criteria for the classification of shock

Dec mean SBP *MAP <60* ---> Regulation fails & hypoperfusion of organs occurs

S&S of neurogenic shock

Dec preload, SV, CO, BP Dec HR Dec UO Dec pulses Narrow pulse pressure (hypotension) Change in LOC Impaired thermoregulatory ability (pt is hypothermic) >3 sec capillary refill *Pt is poikilothermic where they assume the temperature of their environment*

S&S of the hypovolemic stage w/ burns

Dehydration in unburned areas ---> Pt has extreme thirst Hypoproteinemia d/t protein loss in burned area Lymphatic system is overloaded d/t edema Dec kidney perfusion causes negative nitrogen balance ---> Check BUN! Hemoconcentration ---> Inc Hct, blood flow dec RBCs are trapped in burned area, hemolyze, & then cause hematuria HYPERkalemia d/t K+ released from damaged cells, RBCs, & dec UO ---> Leads to heart block & ventricular failure Hyponatremia d/t most of Na being in interstitial space Metabolic *acidosis* Respiratory distress d/t hypovolemic shock & possible inhalation burn

What are the main drugs given for shock?

Depends on the type of shock but most common are: • Volume expanders (albumin, hespan, dextran) • Parental solutions • NE & epinephrine to inc BP • Dobutamine to inc CO & BP • Vasodilators like nitroprusside (Nipride), NTG, hydralazine (Apresolone), labetalol • Diuretics • Antihistamines • Steroids • Bronchodilators • Antidysrhythmics: Amiodarone, adenosine, procainamide, labetalol, verapamil, diltiazem, lidocaine • Abx

Full thickness (3º) burn

Destruction of epidermis, dermis, & *possible damage to SQ layer, muscles, & bone* NERVE ENDINGS ARE DESTROYED ---> Pt can't feel pain over full thickness burn but CAN around the surrounding areas Ex: Burns from fire, hot objects Appearance: Tough, leathery skin, brown/tan/black/red, does NOT blanch on pressure, dull, dry

Hyperacute rejection pt may require what tx?

Dialysis (renal) Plasmapheresis Re-transplanation

S&S of penetrating trauma (such as gunshot wound)

Diffuse or local abdomen tenderness & severe pain Pain at tip of L shoulder (Kerr's sign) Involuntary guarding Abnormal abdominal contour Abrasion, hematoma, multiple bruises Grey Turner's & Cullen's sign Entrance & exit wound Coopernail's sign ---> Ecchymosis of perineum, scrotum, labia ---> Sign of pelvic fracture Cool, pale, clammy skin Tachypnea Oliguria Hypotension, tachycardia Bowel sounds heard in chest Bruit, venous hum, friction rub Shifting of dullness, loss of gastric tympani Pain over lower ribs, symphysis pubis, iliac crest

Flail chest S&S

Dyspnea, tachypnea Splinting w/ respirations Paradoxic chest wall movement Cyanosis Point tenderness Dec/absent breath sounds

How is the CV system affected by shock?

Dysrhythmias lead to ischemia & infarction ---> Treat w/ antidysrhythmics tachycardia/bradycardia <2+ pedal pulses SBP < 90 MAP < 60 ---> Treat w/ vasoconstrictors & positive inotropes Capillary refill > 3 sec

2 states of septic shock

Early (HYPERdynamic, warm): SNS stimulation leads to inc HR, RR, CO, O2 consumption, & myocardial contractility Late (HYPOdynamic, cold): Occurs if there is not tx for early stage

Role of nurse in organ donation process

Early on ID who can be a potential donor Referral to Ohio Procurement Office Liaison w/ donor families or involvement in clinical management of donor Manage client's VS until brain death occurs & donation is complete *Must be able to ID brain death quickly* ---> Lack of responsiveness ---> Absence of cough/gag/corneal reflex ---> Lack of response to painful stimuli

Compensatory stage of shock

Early stage ---> Occurs almost immediately ---> Homeostasis attempts to maintain CO, BP, & tissue perfusion ---> Regulated by SNS RAAS system is stimulation along w/ ADH for Na+ & water retention ACTH is secreted to produced glucocorticoids to inc BS Epinephrine & NE are released to cause vasoconstriction

What happens to the neurological system w/ shock?

Early: • Pt appears anxious, restless, apprehensive Later: • Patient appears confused, disoriented, comatose

Respiratory compensation w/ shock

Early: • Rapid, deep RR = Dec CO2 & respiratory alkalosis ---> Give O2 Late: • Hypoventilation = Dec energy, rapid & shallow RR, inc CO2, & respiratory acidosis ---> Treat w/ intubation & ventilation

Appearances w/ shock

Early: Peripheral vasoconstriction makes pt look pale, cool, clammy & moist Neurogenic shock & early septic shock cause vasodilation so pt look warm, dry, & flushed Anaphylactic shock causes pt to look flushed w/ urticaria, angiodema, & pruritus LAte shock: Pt looks cool, cyanotic, mottled

When caring for a patient w/ MODS, the nurse knows to look for what respiratory symptoms?

Endothelial lung damage Bronchoconstriction & pulmonary vasoconstriction ---> *Biggest thing w/ resp, will cause wheezing* Massive capillary leak causes *pulmonary edema* Altered hydrostatic & oncotic pressure Interstitial edema Potential ventilation-perfusion mismatch ---> May cause ARDS & hypoxia

Partial thickness (2º) burn

Entire epidermis & upper layer of dermis are involved ---> *Sweat glands & hair follicles are still intact* ex: Scaldings, flash burns, flame burns Appearance: Blisters, moist, mottled/pink/red, blanches on pressure & refills VERY painful ---> Will heal in 5-35 days depending on depth

What 3 medications can a nurse give to treat anaphylactic shock?

Epinephrine Antihistamines (Benadryl) Bronchodilator (Aminophylline) ---> Huge complication = palpitations & inc HR

Cardiogenic shock

Failure of heart to adequately pump blood throughout the vasculature as a result of major dysfx of the L ventricle Happens often after MI of L anterior wall ---> LV is affected which dec CO Dec of O2 delivery to tissues 2º to pump failure

We perform kidney transplants on pt stable on dialysis t or f

False We will do kidney transplant if they're no longer stabilized w/ dialysis

High voltage burns --> what will a nurse see?

Flash flame: Causes clothes to burn & a deep skin burn Tissue injury is greatest at contact points & where current arcs Will see: Hypoventilation, CNS dysfunction (?? Long bone fracture & cataract formation ??)

A burn pt has dec protein. What can the nurse do to help w/ this?

Give protein supplements Give albumin NG tube or TPN for feeding ---> NG is preferred as TPN Just inc infection risk of burn pt

Nursing management of a pt w/ a kidney transplant

Goal is to prevent fluid overload, prevent infection, promote diuresis, maintain hydration Assess renal function - Maintain normal BUN - Maintain good I&O - Maintain weight - Maintain stable electrolytes

Complications of pancreas transplant

Graft thrombosis Sudden rise in serum glucose Severe graft pain & inc serum Cr

Contraindications for being a renal recipient

HIV + Chronic active hepatitis Active infection Severe CAD w/ LV dysfx Malignancy Severe PVD/CAD

S&S of compromised airway

Hoarseness Change in voice quality *Wheezing* SQ emphysema w/ laryngeal injury Pink, frothy sputum (pulmonary edema)

A nurse comes up a MVA can see a man is bleeding excessively from a wound on his arm. What should the nurse do?

Hold pressure at the site or directly above the site & wait until help comes

3 types of grafts (temporary)

Homograft: Provided by cadavers Heterograph (xenograph): Provided by skin from another species ---> Replaced q3-4days Synthetic: Provided by manmade substitute w/ skin like properties ---> tegaderm, biobrane ---> 2nd most common type of graft

complications after kidney transplant

Hyperacute rejection ---> occurs within minutes to hours Obstruction of blood which causes dec perfusion Dec UO for a time that causes ATN to occur Can dev infection Can also have fluid & electrolyte imbalances from RAAS syndrome

Hypertonic solutions are given to patients w/...

Hyponatremia & edema

The trauma triad of death

Hypothermia Acidosis Coagulopathy *Greatest risk of death in the first 24 hours after trauma*

Acidosis & trauma

Hypothermia & hypovolemic from bleeding & vasoconstriction cause decreased O2 supply to tissues & cells Resp depression can also cause acidosis

Nursing interventions to establish an adequate circulating volume w/ MODS

Hypovolemia is often the cause of MODS • Avoid fluid overload ---> Causes capillary leaking which worsens pulmonary edema ---> *Balance this w/ diuretics* ---> Monitor I&O • CRRT • PAP monitoring • Monitor serum BUN & Cr • Weigh daily • Insert foley for accurate measurement

2 phases of burns

Hypovolemic Diuretic

A patient has had a severe head injury d/t a MVA. What should be monitored for?

IICP ---> If ICP > 15, it will result in brain ischemia & brain herniation CPP must be at least 70 in order to deliver O2 & glucose to the brain

General rule of hypotension

If a pt remain hypotensive, despite infusion of 2 L of crystalloids (0.9% NaCl) TRANSFUSE BLOOD

GI S&S w/ MODS

Ileus = hypoactive bowel sounds that progress to absent d/t necrosis ---> Copious amounts of NG output (>600 mL/24 hr) means the GI tract is NOT working Anorexia N/V Stress ulcers Constipation/diarrhea Abdominal distention Ascites Hematemesis Melena Jaundice Tendency for upper/lower GI bleed

Pulmonary system effects from shock

Inc capillary permeability = leaking of fluid into lungs w/ leukocytes, platelets, & fibrin Dec surfactant production Collapsed alveoli cause dec lung compliance Pulmonary shunting causes VQ mismatch & ARDS

S&S of diuretic stage of burns

Inc renal flow = diuresis Hemodilution causes dec electrolytes & Hct Possible fluid overload d/t inc IV volume Dehydration may reoccur if the diuresis rapidly depletes restored volume Hyponatremia w/ diuresis & loss ---> *Tremendous shift of Na from high to low, will see a change in LOC* Hypokalemia as it is excreted in urine Hypoproteinemia ---> D/t catabolism of wound, fluid shifts, muscle & tissue damage Metabolic acidosis *High risk for gastric ulcer formation*

What is a L shift of neutrophils?

Indicates that neutrophils present in the blood are at a slightly earlier stage of maturation than usual ---> I.E. band cells Often seen in acute infections

Progressive stage of shock

Intermediate stage Dec tissue perfusion causes inc lactic acid Vasodilation + inc capillary permeability causes: • Dec volume • Tissue edema • Further dec in tissue perfusion *SIRS can occur w/ irreversible cell damage cell death d/t hypoxia*

If a patient has a pelvic injury, what should the nurse monitor for?

Internal hemorrhage because the femoral & aortic a. are in that area

superficial partial thickness(1º) burn

Involves only epidermis ---> Ex: Suburn, low-intensity flash burn, brief scald from hot water Appearance: Dry, red, blanches w/ pressure & refills *Painful because nerves are involved* ---> Heals in 2-5 days w/ no peeling or scarring

What happens w/ shearing or tearing of thoracic structures?

It has a high mortality rate if the aorta, vena cava, or lymphatic vessels are involved Will cause bruit, venous hums, or friction rubs

Viability time of organs

Kidney: 48-72 hr Heart: 4-5 hr Lung: 4-6 hr Liver: 24-36 hr Pancreas: 24 hr *Both heart & lungs must be kept w/ pt's blood circulating throughout while harvesting*

S&S of shock

LOC ranges from inability to concentrate to unconsciousness Pupils may be normal or dilated w/ sluggish reaction Tachypnea Dec UO Thirst Changes in core temp GI bleeding Tachycardia initially then weak, thready pulses, to slow, weak or absent pulses in late stage Edema to anascara (full body edema) Warm & flushed in early stage & then cold/mottled/ashen/cyanotic in later stage ---> Septic shock is esp like this as it is the only shock that starts w/ vasodilation Muscle weakness & wasting Lungs clear (early), may dev ARDS (late) Bowel sounds become hypoactive, paralytic ileus can develop

MODS is most often d/t what issue?

Lack of volume (hypovolemia, sepsis)

What lab value shows that O2 did not make it to the tissues?

Lactic acid ---> The higher it gets, the most cell death that occurs Normal =0.5-1.5

Refractory stage of shock

Late stage ---> "irreversible shock" ---> Death is imminent Shock is unresponsive to therapy & thus leads to death

Hepatic system effects d/t shock

Liver is impaired because of cellular damage w/ anaerobic metabolism | | V Causes: • Inc unconguated bilirubin which can lead to jaundice • Inc waste products (ammonia, lactate) • Dec drug metabolism (leads to toxic levels, asterixis) • Dec ability to neutralize microorganisms causes inc risk of infection

Criteria for organ donor

Look at age Patient must meet brain death criteria w/ intact HR Vasopressors are acceptable if they're being used to maintain BP & HR until organ is donated

Hypovolemic shock

Loss of intravascular blood volume Results from • Internal bleeding • Long bone fracture • Ruptured spleen • Surgical procedure • 3rd spacing (ex: Ascites) • Trauma • GI losses (Vomiting, diarrhea) • Addison's disease • DI • Excessive diuresis (HHNK, DKA)

Contraindications to being a heart transplant candidate

Malignancy Active infection Autoimmune d/o Irreversible kidney/lung/liver disease Severely elevated PVR PUD CVA PVD DM Obesity

Hyperacute rejection

Minutes to hours after transplant Caused by presence of antibodies to organ's antigens Organ become necrosed

Nursing management of post-organ transplant

Monitor & assess graft function Monitor & assess fluid electrolyte status Administer all ordered immunosuppressive agents & pain meds Monitor & asses for rejection, infection, & bleeding HD before transplant Cardiac monitoring throughout process

When assessing a trauma pt's breathing, the nurse knows what disease states put a patient at risk for altered breathing?

Multiple rib fracture ---> ≥2 rib fractures = flail chest Tension pneumothorax ETOH/alcohol abuse *Needle thoracotomy can relieve pressure*

Septic Shock S&S

Must have 2 or more of the following s&s: • Temp >38.3ºC or <36º • HR > 90 • RR > 20 • PaCO2 <32 • WBCs >12,000 or <4,000 • Bands >10%

Monitoring renal transplant patient

Must have ESRD ---> Most often caused by HTN, diabetes, congenital disease ---> May be anemic

Effects of MODS on the CV system

Myocardial ischemia Dec contractility causes dec CO, hypotension, & a change in heart rhythm

Renal system & its effects d/t shock

Normally, the kidneys receive 1.3L of blood/min With shock, the kidneys receive <200 mL/min *Treat w/ fluid resuscitation* Dec UO & metabolic acidosis can occur

4º burn

Not often used Described as an injury that occurs to muscle, bone, SQ fat Some call this a full-thickness burn

S&S of anaphylactic shock

Occurs within 20 mins of insult • Warm, flushed d/t vasodilation • Urticaria & pruritus • *WHEEZING* d/t bronchoconstriction • Resp distress • Angioedema • Hoarseness/stridor • Laryngeal edema w/ wheeze • Dec SVR ---> causes blood to pool in periphery which dec CO, CI, PAP, & CVP *Progresses to death very quickly*

Complications of heart transplant

Organ dysfx ---> SOB, S3, S4, dec EF, fatigue, dec BP, dec HR Infection JVD Malignancy Rejection (malaise, weight gain, S&S of CHF, chest discomfort)

Hematological lab value changes w/ MODS

PT, APTT >25% normall FSP > 10mg/ml Dec fibrinogen, Hgb, & Hct Plt < 100,000 WBCs initially >10,000 & the later <5,000 d-Dimer positive

What should a nurse expect to see in a pt w/ hypovolemic shock?

Pale/cool skin Dec peripheral pulses Hypotension Inc RR & HR Resp alkalosis Flat jugular vein (dec CVP & PAP) Dec UO

Uniform determination of death act

Person is considered dead if they have: -- Irreversible cessation of circulatory & respiratory function --- Irreversible cessation of functions of the entire brain, including the brain stem

Contraindications for liver transplant

Portal vein thrombosis Active alcoholism Active infection Malignancy Advanced cardiopulmonary disease

Contraindication for organ transplant

Presence of active systemic infection Malignant disease (except skin CA) Active PUD Active abuse of alcohol or other substances Severe damage or systems other than that which needs to be transplanted Severe psychiatric disease Demonstration of past or current inability to comply w/ prescribed medical regiment Lack of functional support system Lack of sufficient financial resources to pay for surgery, hospitalization, medication, & follow-up care

Neurogenic shock

Primary caused by SCI & upper mid thoracic region, high spinal anesthesia ---> SPINAL SHOCK Big thing is to stablize spin Pt will have generalized vasodilation w/ massive inc in vascular capacity ---> Pooling of blood in periphery ---> Dec venous return to heart

Nursing management of *High risk for self-care deficit* w/ burn pt

Provide active/passive ROM Prevent edema, atrophy, & ligament shortening in hands & feet Elevate hands & feet Provide splints

Complications of liver transplant

Rejection ---> Usually occurs 7-10 days after surgery ---> Confirmed by biopsy ---> Liver enzymes inc, become jaundiced, tea colored urine, clay colored stools, steatorrhea Hepatic a. thrombosis Biliary obstruction

Anaphylactic shock

Result of antigen-antibody rxn where is histamine is released ---> Causes vasodilation plus loss of fluid & protein into tissue spaced ---> Dec venous return to heart & pooling of blood in periphery Often done after exposure to drugs, food, insect venom, allergens

A patient presents to the ER with difficulty breathing and rapid, shallow respirations. They are trying to not breathe deeply because of pain and are unwilling to cough deeply. What does this signify?

Rib fractures

What would a nurse look for if an internal bleed is suspected?

S&S of shock Cullen sign (bleeding around umbilicus) Grey turner (bleeding in flank) Inc in abdominal girth Flank pain/inc back discomfort Hematuria

Low voltage burns --> What will a nurse see?

Seen more w/ children (sucking on electrical cord) Edema, cardiac dysrhythmias, v. fib

Hypothermia leads to what 3 problems?

Sepsis Acidosis Multiple organ failure ---> ≥4 organs involved = 99% mortality

What causes sepsis?

Sepsis is when organisms invaded the body & stimulate a generalized inflammatory response ----> Causes inc blood flow & vascular permeability Most common causes: • Gram neg bacteria: E. coli, pseudomonas, klebsiella, enterobacter • Gram pos bacteria: Staph, strep Release of endotoxins from bacteria causes inc prostaglandin production, inc renal blood flow, bronchodilator, venoconstriction, plt aggregation, vasoconstriction, & pulmonary HTN ----> Leads to maldistribution of circulatory volume ---> Causes imbalanced O2 supply & demand

Lab changes w/ MODS

Serum Cr >2.0 mg/dl BUN >20 mg/dl K+ >5 mEq/L *Calcium <8.5 mg/dl* Mg <1.5 mEq/L

What are the S&S of diaphragmatic rupture?

Severe pain radiating to shoulder Dyspnea Dec breath sounds Signs of shock

Hematological system w/ shock

Sluggish blood flow allows for formation of microemboli & DVT/PE Hypoperfusion to the liver causes dec clotting factors which puts pt at risk for DIC Early on, pt will have leukopenia

Nursing management of neurogenic shock

Stabilize spinal cord Give analgesics Ensure proper positioning w/ spinal anesthesia Normalize temperature

How can the nurse maintain airway w/ a trauma pt?

Stabilize the neck *ALL TRAUMA PT REQUIRE SUPPLEMENTAL O2* ---> If breathing spontaneous, give a non-rebreather w/ 100% FiO2 ---> If not breathing spontaneously (RR <6), do mechanical ventilation • Clear airway if an obstruction is seen

Complications of lung transplant

Surgical side effects Graft dysfx Bronchiolitis obliterans ---> Severe SOB ---> Must be treated with IV steroids, cytolytic therapy

Organ recovery

Surgical team on standby to remove organ

What is the body's response to burns?

Systemic response w/ maximum edema & fluid shift Dec CO, inc PVR, increased capillary permeability ---> Dec BP & inc HR Hemodynamic changes: Inc SVR & after loads d/t vasoconstrictors & inc blood viscosity Hyperventilation d/t pain ---> Causes mild hypoxemia & respiratory alkalosis ---> May be a dec in surfactant if respiratory tract is affected If renal system is affected, will have oliguria r/t dec blood flow & dec GFR If GI system is affected, stress ulcers, paralytic ileus, & GI bleeds can occur Inc glucagon, cortisol, & catecholamines (Possible hyperglycemia?) Dec in insulin, T3, & T4

S&S of CV failure w/ MODS

Tachycardia Bounding or diminished pulses MAP <70 mmHg Intractable dysrhythmias CVP <8 mmHg CO initially >8L/min & then later <4 L/min CI initially >4 L/min & then late <2.5 L/min Skin initially warm & then later cool & clammy Pale skin Peripheral edema S3 heart sound

S&S of respiratory failure w/ MODS

Tachypnea ---> Pt becomes alkalotic & then acidotic later Dyspnea Crackles d/t capillary leak & pulmonary edema Pulmonary HTN

A trauma patient comes in multiple organ failure and a core body temp of 96ºF. The nurse knows that what must be done before declaring the patient deceased?

Temp > 98ºF

A construction worker fall on a very tall ladder and presents in the ER with asymmetric chest movement, tracheal deviation, and is tachypneic & pale. What does the nurse suspect & what should she further assess for?

Tension pneumothorax Assess: Further for S&S of shock, S&S of dec venous return, muffled heart sounds

When someone has a pelvic injury, what are two common medications given?

Tetanus shot Prophylactic abx --> These pt are at high risk for infection

What is the first system impacted by shock?

The GI system Leak of proteins from IV space alters the blood flow to the GI ---> Dec motility Pt can dev: Stress ulcers, paralytic ileus, & GI bleeds *treat w/ PPIs, gastric acid reducers*

Why are severe burns critical?

The patient loses: • Protective barrier against infections • Body fluids • Temperature control • Sweat & sebaceous glands • Number of sensory receptors

Why is an MRI contraindicated w/ a gunshot victim?

There may be bullet fragments still inside the pt so an MRI would cause further harm

What is dangerous thing about electrical burns?

They affect the heart and will stop it almost instantaneously

Criteria for transplant waiting list

Urgency of need Blood type Recipient weight & heigh *If they're waiting & stable they must:* • Stay at home or near transplant center • Have cell phone or beeper • If live >2 hr from center, they must relocate to be closer to center or arrange air transportation *If waiting & unstable:* • May stay in hospital until transplant • May live outside hospital but w/ continuous inotropic support

What S&S might you see which would make you suspect an inhalation burn?

Voice change (hoarseness) Color change Difficulty breathing Hypoxia Brassy cough Stridor/wheeze *Priority = airway management*

Treatment of cardiogenic shock

Want to improve the pumping action of the heart ---> *Diuretics* if there is too much fluid in intravascular space ---> Give *pos inotropic medications* (Dobutrex, Dopamine, Inocor) *** Inc force of contractility, HR, & EF ---> Use when SBP <100mmHg (dopamine preferred) *Amrinone (Inocor)* can inc contraction w/o stimulating SNS ---> Give *vasoactive drugs* (Nipride/NTG) which dec preload & afterload ---> Helps w/ L & R HF but most pt don't tolerate it well because they already have dec BP *IABP*: Inc SV, inc diastolic coronary a. perfusion, dec afterload & workload of heart

S&S of early septic shock

Warm, flushed skin d/t vasodilation Rapid, bounding pulse Change in LOC Fever, chills Hypoxemia Dec UO Metabolic acidosis Inc WBCs & FSP, dec plt

How do we tell if the brain has irreversible cessation of functions?

We do a blood study for perfusion to brain

dopamine & burns

When we give dopamine for burns, we are giving it for the function of inc BP (cardiac function) Thus we give it 5 mcg/kg/min ---> Side effect = inc HR Therefore, do NOT give dopamine to someone w/ a HIGH HR already & ALWAYS monitor for tachycardia

Nosocomial infections are seen when w/ transplant pt?

Within 1st month, at least 1-6 mo

Acute rejection

Within first 3 mo T cells & B cells are both trying to fight the transplant Determined by biopsy *put these pt on high dose steroids*

Isotonic solutions are given to pt w/

dehydration/hypovolemia ---> Ex: Vomiting, diarrhea

You can get malignancy in a transplant organ t or f

true Caused by post-transplantation immune deficiency

What is the ABCDE of trauma?

• *A*irway maintenance w/ cervical spine protection • *B*reathing • *C*irculation • *D*isability (neuro status( • *E*xposure

Types of chest trauma

• *Simple, closed pneumothorax* • *Hemothorax* ---> Massive bleeding = >1500 ml & must be treated immediately • *Open pneumothorax*: Caused by injury that perforates the chest wall or pleural space ---> Lung on that side collapses ---> Mediastinum shift to opposite side ---> Trachea shifts away from injured side (late sign) • *Pulmonary contusion*: Bruising of lung which causes inflammation & edema w/ dec respiratory compliance ---> Can take up to 72 hrs to dev • *Cardiac tamponade:* Accumulation of blood in pericardial sac ---> Beck's triad ---> Treat w/ pericardiocentesis • *Blunt cardiac injury:* Myocardial contusion, concussion, or rupture ---> Causes dysrhythmias ---> Monitor any pt w/ sternal or pulmonary contusion for 24 hrs • *Flail chest:* ≥2 ribs fractures, no longer attached to sternum • *Diaphragmatic rupture:* Caused by injury from steering wheel ---> Causes herniation of abdominal contents into the thoracic cavity

What are the types of rib fractures & what should a nurse watch out for w/ them?

• 1st or 2nd fracture ---> Seen w/ intrathoracic vascular injury • Middle rib fracture ---> Seen w/ lung injury (Pneumothorax) • Lower rib fracture ---> Seen w/ abdominal injury ---> Spleen & liver injuries • Sternal fracture ---> Watch for dysrhythmias

A patient was hit with a baseball bat and has a pulmonary contusion. What are the signs of this?

• Chest pain • Contusion/abrasions on skin, over the site • Rib fractures/flail chest • Tachypnea, dyspnea • Hemoptysis • Ineffective cough w/ copious secretions • Fever • Moist crackles • Dec PaO2 & pH • Evidence of the injury on Xray after 24 hrs

What evaluations must be done for organ transplant?

• Client must medically need transplant • Transplant must be surgically feasible • Client must have suitable psychosocial status ---> Proper coping skills ---> Look at hx of compliance w/ other meds ---> Must have availability of support systems ---> Must have proper living conditions ---> Must have proper social habits (no smoking/drinking/illicit drugs) • Immunologic status

A nurse is caring for a MVA patient who lost a large amount of blood & is experiencing respiratory depression. What clinical S&S would make the nurse suspect acidosis is occurring?

• Dec LOC • Dec cardiac function • Arterial lactate >2 • Base deficit <-2 • Serum pH <7.2 • Lactic acid

A nurse is assessing a woman who was involved in a MVA. The nurse suspects the woman has a closed pneumothorax. What S&S would make the nurse think that?

• Dyspnea/tachypnea/resp distress • Cyanosis, crepitus • Diminished or absent breath sounds • Hyperresonance over affected site • Sudden drop in PaO2

5 primary goals of care w/ MODS

• Establish adequate oxygenation • Establish adequate circulating volume • Cardiovascular support • Prevent/control infections • Pt & family support

Interventions for airway management

• If GCS < 8, use a ventilator • If pt has a facial or skull fracture, do oropharyngeal intubation • Use head block, cervical collar, or spine board to stabilize spine • Do jaw thrust maneuver to maintain cervical spine alignment & airway

When a pt has a new heart transplant, they will have what occur?

• Inc resting HR • Gradual inc in HR w/ exercise w a delayed return to baseline • Absence of angina • Enhanced response to certain drugs (adrenaline) & dec response to others (atropine & digoxin) • 2 P waves may be seen on monitor (one from recipient & one from donor) • ONLY the donor's heart SA node is regulating electrical conduction

What factors potentiate hypothermia with trauma?

• Lack of clotting • Open body cavities • Massive fluid replacement ---> A lot of fluid can lower temp ---> Put fluids in fluid warmer first • Administration of certain drugs ---> Muscle relaxants, sedatives, anesthestics or opioids, vasodilators • Severity of injury • Amount of blood loss • Alcohol consumption ---> Causes vessels to dilate & lose temperature regulation

Nursing interventions for promoting cardiovascular suppose in a patient w/ MODS

• Monitor CO, CI, SVR, PAP, & CVP • Use crystalloid therapy ---> Minimize movement of fluid into interstitial spaces ---> Most common = 0.9% NaCl • Dysrhythmias ---> Give meds as needed ---> *Most common = PCVs bc of the irritability caused by dec perfusion* ---> May also be d/t high or low K+ & low Ca+

Beck's triad

• NVD • Narrow pulse pressure (hypotension) • Muffled heart sounds D/t compression of heart because of blood in pericardial sac which causes dec CO

Nursing interventions to prevent/control infections w/ MODS

• Try to find the cause ---> Culture sputum, blood, wound, etc ---> Peritoneal lavage to see if there's infection in peritoneal cavity • Debride wounds • Stabilize fractures, prevent fat emboli • Minimize tissue damage • Prophylactic abx (Broad spectrum) ---> Vancomycin, Zosyn, piperacillin, Keflex • Use aseptic technique • Provide nutritional support