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adult health ii > Care of Patient With Shock (exam 1) > Flashcards

Care of Patient With Shock (exam 1) Flashcards

1
Q

What is the #1 nursing diagnosis for shock?

A

ineffective tissue perfusion

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2
Q

Shock is widespread ____ cellular metabolism.

A

abnormal

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3
Q

During shock ___ and ___ needs are not met.

A

oxygenation and tissue perfusion

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4
Q

Shock is also called…

A

Whole body response syndrome

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5
Q

Any problem impairing ____ delivery to ____ and ___ can start shock, leading to life threatening emergency

A

oxygen; tissues and organs

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6
Q

Stages of shock include:

A

initial. nonprogressive, progressive, refractory

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7
Q

initial stage is…

A
  1. (early shock)

2. baseline MAP decreased by

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8
Q

Nonprogressive stage is….

A
  1. (compensatory stage)
  2. MAP decreases by 10 to 15 mm Hg
  3. kidney and hormonal adaptive mechanisms activated (decreased UOP to compensate for fluid loss)
  4. tissue hypoxia in nonvital organs (skin, GI tract)
  5. acidosis and hyperkalemia.
    * **Stopping conditions that started shock and supportive interventions can prevent shock from progressing
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9
Q

Progressive stage is….

A
  1. (intermediate stage)
  2. sustained decreased in MAP of >20mm Hg
  3. vital organs develop hypoxia
  4. life threatening emergency
    * ***Conditions causing shock must be corrected with 1 hour of progressive stage onset. Afterwards body will not respond to treatment
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10
Q

Refractory stage is….

A
  1. (irreversible stage)
  2. too little oxygen reaches tissues, cell death and tissue damage result
  3. body cannot respond effectively to interventions; shock continues
    * ***Rapid LOC, nonpalpable pulse, cold, dusky extremities; slow, shallow respirations; unmeasureable oxygen sat.
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11
Q

What are the types of shock?

A
  1. hypovolemic
  2. cardiogenic
  3. distributive
  4. obstructive
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12
Q

Hypovolemic shock is…

A

total body fluid decreased (blood loss from poor clotting with hemorrhage, dehydration)

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13
Q

Cardiogenic shock is…

A

direct pump failure, failure of blood to move forward(MI, cardiac arrest, Ventricular dysrhthmias, cardiomyopathies)

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14
Q

Distributive shock is…

A

(burn shock), fluid shift from central vascular space, maldistribution of blood volume, not where its suppose to be ( neural induced-pain, stress, head trauma, chemical induced- anaphylaxis, sepsis, burns, liver impairment)

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15
Q

Obstructive shock is…

A

(physical), cardiac function decreased by non-cardiac factor, indirect pump failure (PE, cardiac tamponade, thoracic tumors, pulmonary HTN, arterial stenosis, tension pneumothorax)

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16
Q

What physical assessments/ clinical manifestations should be done on these patients?

A
  1. cardiovascular
  2. pulse
  3. BP
  4. O2 sat.
  5. skin
  6. respiratory
  7. renal and urinary
  8. CNS
  9. muscloskeletal
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17
Q

What assessment should be done for these patents?

A
  1. psychosocial (sense of doom, anxiety)
  2. labs (CBC, lactic acid, ABGs, electrolytes)
  3. hemodynamics (BP, MAP, CO or CI, SVR, CVP, SV, SVV, PA pressures, ScVO2)
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18
Q

What are some nonsurgical management things that should be done for these patients?

A
  1. maintain tissue oxygenation, increase vascular volume to normal range, support compensatory mechanisms
  2. oxygen therapy
  3. IV therapy (IV access) with NS or RL
  4. Drug therapy (if fluids are not effective)
    THE GOAL IS TO MAINTAIN PERFUSION
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19
Q

What kind of drugs therapy is given?

A
  1. vasopressors
  2. agents enhancing contractility
  3. agents that vasodilate
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20
Q

What vasopressors are given?

A
  1. dopamine
  2. epinephrine
  3. norephinephrine
  4. phenyleprine
  5. vasopressin
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21
Q

What agents are given that enhances contractility?

A
  1. milrinone

2. dobutamine

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22
Q

What agents are given to dilate?

A
  1. sodium nitroprusside

2. nitroglycerine

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23
Q

During hypovolemic shock, low circulating blood volume causes MAP to ____resulting in inadequate total body ____

A

decrease, oxygenation

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24
Q

Hypovolemic shock is commonly caused by ____ or____

A

hemorrhage (external or internal) or dehydration

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25
Q

Symptoms of hypovolemic shock…

A

increased HR
decreased BP (vasoconstriction constriction)
narrowed pulse pressure (systolic BP decreased)
postural hypotension
flat neck and hand veins independent position
slow capillary refill
diminished peripheral pulses
pale, cool, moist skin (vasoconstriction)
decreased CO/CI
Low CVP
decreased PAWP
increased SVR
increased RR (respiratory alkalosis, decreased PCO2 and PAO2,)
shallow depth of RR

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26
Q

During cardiogenic shock the actual heart muscle is ____, pumping is ___ impaired.

A

unhealthy, directly

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27
Q

Cradiogenic shock is failure of the blood flow to move ___.

A

forward

28
Q

Most common cause of cardiogenic shock is ____

A

MI

29
Q

Symptoms of cardiogenic shock…. (fluid overload)

A 
SBP  30 mmHg
tachycardia
weak, theady pulse
diminished heart sounds
decreased LOC
cool, pale moist skin
decreased UOP
chest pain (because of decrease in oxygen)
dyrhtyhmias
increased RR, tachypnea
crackles (fluid backing up in lungs)
decreased CO 
CI
30
Q

During distributive shock blood volume distributed to ___ tissues where it can not circulate, deliver oxygen

A

interstitial

31
Q

Distributive shock is caused by

A

loss of sympathetic tone
blood vessel dilation
pooling of blood in venous and capillary beds
capillary leak

32
Q

What are the types of distributive shock

A

neural induced (neurogenic) and chemical induced (anaphylaxis, sepsis, capillary leak syndrome)

33
Q

Symptoms of distributive shock…. (anaphylaxis)

A 
decreased BP
increased HR, tachycardia
increased RR, tachypnea
cough, dysphagia,
hoarseness 
stridor, wheezing, rales, rhonchi
restlessness, anxiety, apprehension
pruritis, erythema, urticaria
angioedema
decreased CO/CI, CVP, PAWP, SVR (dilation)
34
Q

Symptoms of distributive shock…. (neurogenic)

A 
hypotension
bradycardia
warm, dry skin
hypothermia
bounding pulse
decreased CO/CI, PAWP, CVP, SVR (dilation)
35
Q

Symptoms of distributive shock…. (septic)

A 
increased HR
decreased BP
wide pulse pressure (diastolic decreased)
full, bounding pulse
pink, warm, flushed skin
increased RR
crackles
decreased LOC
increased temp
increased CO/CI
decreased SVR, CVP, PAWP (dilation)
increased SvO2 (venous blood that comes back to heart)
36
Q

During obstructive shock there is an impaired ability of ____ heart muscle to pump effectively

A

normal

37
Q

In obstructive shock there are conditions ___ heart preventing either ___ of the heart or adequate ___ of the healthy heart muscle.

A

outside; filling; contraction

38
Q

The most common cause of obstructive shock is…

A

***pericarditis

other causes are cardiac tamponade and PE

39
Q

Symptoms of obstructive shock…. (PE)

A 
decreased BP
tachycardia
distended neck veins
tachypnea
restlessness, anxiety
impending sense of doom
crackles
pleural friction rub
cool, moist skin
increased PA pressures (directly related to problem)
decreased CO/CI
40
Q

Generalized systemic inflammation in organs remote from the initial injury is….

A

SIRS (system inflammatory response syndrome)

41
Q

SIRS occurs in ___% of patients in critical care

A

50

42
Q

SIRS etiology:

A
  1. due to infection

2. due to noninfectious source (thromboembolism, autoimmune disorder, pancreatitis)

43
Q

SIRS can be diagnosed when ___ clinical manifestations are present.

A

2 or more

44
Q

Manifestations of SIRS include:

A
  1. temp >38 or 90

3. **RR >20 or PaCO2 12,000 or

45
Q

Uncontrolled inflammation or infection, persistent hypoperfusion, flow dependent oxygen consumption (VO2), and/or persence of necrotic tissue.

A

MODS (multiple organ dysfunction syndrome)

46
Q

MODS is a ___ of cell damage caused by massive release of toxic metabolites and enzymes.

A

sequence

47
Q

MODS is ____ depressant factor from ischemic pancreas

A

myocardial

48
Q

MODS can result from ___

A

SIRS

49
Q

MODS is ____ form

A

microthrombi

50
Q

MODS is progressive failure of ____ interdependent organ systems

A

2 or more

51
Q

MODS had a ___ mortality rate

A

high

52
Q

A systemic response to an infection is called?

A

sepsis

53
Q

Sources of sepsis include:

A
  1. gram negative bacteria (almost half the cases)
  2. gram positive bacteria (rising in number)
  3. fungi
  4. viruses
54
Q

Prevention of sepsis include:

A
  1. hand hygiene
  2. assessing
  3. looking for source on infection
  4. assessing central lines, catheters, IV lines
55
Q

Symptoms of sepsis include:

A
  1. temp >38 or 90
  2. RR >20
  3. altered mental status
    • fluid balance >20 mL/kg in 24 hrs
  5. glucose >140 (glucose increases with inflammation)
  6. WBC >12,000 or 10% bands
  7. elevated c reactive protein (inflammatory marker
  8. elevated plasma procalcitonin (inflammatory marker)
  9. SBP 40
  10. MAP 70%
  11. CI >3.5
  12. serum lactate >1
  13. Pao2/Fio2 0.5 (because kidneys aren’t working)
  14. INR >1.5 or aPPT >60 sec
  15. absent bowel sounds
  16. PLT 4
56
Q

Sepsis include shock with hypotension despite adequate fluid resuscitation (death rate for this patient exceeds 40%)

A

septic shock

57
Q

During septic shock there is a presence of perfusion abnormalities which may include:

A
  1. lactic acidosis (metabolic acidosis)
  2. oliguria
  3. mental status alteration
58
Q

Cardiovascular changes during septic shock include:

A
  1. peripheral vasodilation
  2. relative hypovolemia
  3. increased capillary permability, loss of intravascular volume, preload reduced, CO increased
  4. decreased tissue perfusion
  5. inadequate oxygen delivery to the cells
59
Q

Neuo and endocrine changes during septic shock include:

A
  1. SNS stimulated—ACTH
  2. release or epinephrine, norepinephrine, glucocorticoids, aldosterone, glucagon, renin
  3. hypermetabolic state
  4. relative insulin resistance (increased glucose)
  5. mitochondrial dysfunction (can’t receive oxygen)
60
Q

Complications of septic shock include:

A
  1. Cardiac failure
  2. ARDS
  3. ATN (renal)
  4. DIC
  5. shock liver, ischemic injury to GI tract
61
Q

What is the treat for DIC?

A
  1. give clotting factors (platelets)
  2. fluids
  3. heparin
62
Q

intervemtions for DIC include:

A
  1. prevention (hand hygiene, take out lines, no sick visitors)
  2. early recognition (assess vitals)
  3. fluid therapy
  4. oxygen therapy
  5. drug therapy
  6. watch for signs of bruising easily, blood in stool, small petechiae spots, small occlusion in peripheral, bleeding gums, oozing blood from sites
63
Q

What does the SOFA (quickSOFA) score include?

A
  1. 3 items measured, one point each (respiratory >=22, altered mental status, SBP= 2 associated with poor outcomes
64
Q

Treatment includes:

A
  1. initial fluid resuscitation foe severe sepsis (>1 liter crystalliod,
    30mL/kg of NS in the first 4-6 hours, incremental fluid bolus depending on patent responsiveness
  2. norepinephrine IV gtt (1st choice vasopressor)
  3. corticosteroid therapy (hydrocortisone) only if fluid and vasopressor therapy not effective
65
Q

What should be done within 3 hours?

A
  1. measure lactate level
  2. obtain blood cultures prior to administrating antibiotics
  3. administer 30mL/kg of crystalloid for hypotension or lactate >4
66
Q

What should be done within 6 hours?

A
  1. apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a MAP >= 65
  2. reassess volume status and tissue perfusion
  3. remeasure lactate if initial lactate elevated

adult health ii (4 decks)

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