CH.39 - Shock Flashcards
Normal PaO2
80-100 mmHg
Normal PaCO2
35-45 mmHg
Normal Lactic Acid (arterial)
0.3-0.8 mmol/L
Hematocrit:
Females: 37-47%
Males: 42-52%
Hemoglobin
Females: 12-16 g/dL
Males: 14-18 g/dL
Lab changes expected w hypovolemic shock
- Decreased pH due to anaerobic metabolism.
- Decreased PaO2.
- Increased PaCO2.
- Increased lactic acid.
- increased H&H, if shock is due to dehydration or fluid shift.
- Decreased H&H if shock is due to hemorrhage.
- Increased potassium due to dehydration and acidosis.
Earliest manifestations of shock
Increased heart rate (tachycardia).
Early clinical signs of hypovolemic shock
Increased heart rate, narrowing pulse pressure, increased respiratory rate, decreased urine output, skin cool and clammy, slow capref, persistent thirst, restless, agitated, anxious, muscle weakness and pain due to lactic acid.
Ringer’s Lactate
Sodium, chloride, calcium, potassium, and lactate disolved in water.
IV Therapy products for hypovolemic shock
Crystalloid fluids: Normal saline or Ringer’s lactate. Colloid fluids: Whole blood and PRBCs including H&H - human plasma - if H&H normal. Plasma protein fractions (Plasmanate) and synthetic plasma expanders (hetastarch, Hespan) for early treatment before cause of hypovolemic shock is known.
SIRS
Systemic inflammatory response syndrome (early sepsis). Pathophysiology: Increased release of proinflammatory cytokines by WBCs (capillary leak), vasodilation, pooling of blood, vascular damage, formation of microthrombi in capillaries, cellular hypoxia.
Severe Sepsis
Pathophysiology: Cell anoxia, cell death, release of metabolites, microthrombi consume platelets and clotting factors, triggers more proinflammatory cytokines organ failure. Clinical signs: Lower O2 Saturation, rapid respiratory rate, decreased or absent urine output, change in patient cognition or affect.
Lab Values associated with sepsis
Increasing serum lactate level, normal or low total WBC w/ left shift (decreased segs, increased bands)
SIRS Criteria
Temp greater than 100.4 F or 96.8 F. HR greater than 90 bpm Resp rate greater than 20 BPM PaCO2 less than 32 mmHg Abnormal WBC Count: Greater than 12,000/ mm3 or less than 4000/mm3, or greater than 10% bands.
Sepsis Criteria
Two or more SIRS criteria present plus: Presence of any known infection and one of the following clinical manifestations: Hypotension Urine output less than expected Positive fluid balance Decreased capref Hyperglycemia (greater than 120 mg/dL in the absence of known DM) Unexplained change in mental status
The client who is exposed to invaders recovers rapidly after the invasion without damage to healthy body cells. How has the immune response protected the client?
A. Intact skin and mucous membranes
B. Self-tolerance
C. Inflammatory response against invading foreign proteins
D. Antibody-antigen interaction
B. SELF TOLERANCE
Which statement accurately explains otitis media?
A. The inflammatory response is triggered by the invasion of foreign proteins.
B. Phagocytosis by macrophages and neutrophils destroys and eliminates foreign invaders.
C. It is caused by a left shift or increase in immature neutrophils.
D. Many immune system cells released into the blood have specific effects.
A. The inflammatory response is triggered by the invasion of foreign proteins.
A complete blood count with differential is performed in the client with chronic sinusitis. Which finding does the nurse expect? A. Segmented neutrophils, 62% B. Lymphocytes, 28% C. Bands, 5% D. Basophils, 4%
D. Basophils, 4%
The nurse is preparing the client for discharge on postoperative day 1after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client’s discharge plan?
A. “Please report any increased redness, swelling, warmth, pain, or lack of movement to your health care provider.”
B. “Do not allow anyone to take your blood pressure or draw blood on the side where you had your breast removed.”
C, “A referral has been made to the American Cancer Society’s Reach to Recovery program, and a volunteer will call you next week.”
D. “Avoid the prone and hunched-back positions, and ask your health care provider for any other needed activity restrictions.”
A. “Please report any increased redness, swelling, warmth, pain, or lack of movement to your health care provider.”
Because of a flu epidemic, the respiratory floor of a hospital does not have any open beds. Which client does the nurse determine is ready for discharge at the request of the discharge planner?
A. Older adult client with a history of congestive heart failure, oxygen saturation of 91%, and on O2 at 2 L, with white blood cell count (WBC) 15.5, segs 8.0, bands 5, lungs with slight crackles in bases, able to assist with activities of daily living (ADLs), and afebrile
B. Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, white blood cell count (WBC) 9.5, segs 6.0, bands 1.0, oxygen saturation of 93% on room air, and afebrile
C. Young adult client with crackles in all lung lobes, with productive cough of copious amounts of thick yellow sputum, white blood cell count (WBC) 20.0, segs 7.0, bands 10.0, oxygen saturation of 95% on O2 at 2 L, and temperature of 100.4° F (38° C)
D. Older adult client with recent history of right hip replacement, with productive cough, white blood cell count (WBC) 3.4, segs 6.2, bands 5, lungs with crackles right mid-lobe posterior chest wall, oxygen saturation of 89% with O2 at 2 L, and afebrile
B. Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, white blood cell count (WBC) 9.5, segs 6.0, bands 1.0, oxygen saturation of 93% on room air, and afebrile
