Shock
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