Exam 1 Flashcards
Shock S/S
~Neuro
Early: anxiety, restlessness, increased thirst
Late: ↓ CNS (lethargy,) AMS, weakness, diminished/absent deep tendon reflexes, sluggish pupils
Shock S/Sx
~Cardiac:
↓ cardiac output,↓ bp
↑ hr
Thready/weak pulses, narrowed pulse pressure, decreased peripheral pulses
↓JVP, flat veins (neck, hand)
Slow cap refill
Shock S/S:
~respiratory
↑ rr
Shallow breathing
↓PaCo2 →↑
Cyanosis (nail beds /lips)
Shock S/S
~ gi
↓ motility
Diminished / absent bowel sounds
N/V/constipation
Shock S/S:
~GU
↓ urine output
↑ specific gravity
Sugar/acetone in urin
Shock S/S:
~skin
Cool → cold
Pale → mottled → cyanotic
Dry mouth
↓ cap refill
How to calculate MAP?
SBP+ 2 (DBP) and divide by 3
What happens to MAP during shock?
↓ due to ↓ total blood volume / cardiac output ( hr x stroke volume) and size/integrity of vascular bed
What level do we want the map to be?
> 65
What 3 things does hemorrhage lead to?
↓ venous return =↓ JVP
↓ bp
Hypovolemic shock → insufficient organ perfusion
What 2 things does trauma cause?
Hemorrhage
Third spacing of fluid
What 2 things happen w/ third spacing of fluid?
Hypovolemic shock
Ruptured vessels leaking into large cavities and ↑ inflammatory mediators
Insufficient organ perfusion
~ Brain
Cerebral hypoxia = progressive ↓ in LOC
Insufficient organ perfusion
~ cardiac
↓ bp =↑ hr
↓ myocardial contractility (from lactic acidosis) = PEA
Insufficient organ perfusion
~ kidneys
A renal perfusion
= renal ischemia = acute tubular necrosis = renal failure
↓ GFR = oliguria
Insufficient organ perfusion
~ skin
Body vasoconstricts - preserves circulation to vital organs
= cold mottled extremities
Insufficient organ perfusion
~ all body tissue
↓ lactate clearance (liver, kidneys, skeletal muscle)
= lactic acidosis
What are the 4 stages of shock?
- Initial stage
- Compensatory stage
- Progressive stage
- Refractory/MODS stage
Describe initial stage of shock
What is the alert?
↓MAP 5-10
↑ hr, mild vasoconstriction
Body compensates well, maintaining bp and perfuse to vital organs
Normal range for cardiac output and MAP
Alert: ↑ hr/rr may be the only sign
Describe the compensatory stage of shock
↓ map: 10-15
Kidney/hormonal mechanisms activated to maintain MAP
• ↑ renin, ADH, aldosterone, epi and norepinephrine
↓ urination, ↑ Na +, ↑ blood vessel constriction
↓ tissue hypoxia to vital organs (no permanent damage)
↓ blood ph= acidosis
↑ K+
S/S shock
~ objective
~ subjective
~ objective: restlessness, ↑ hr/rr, ↑DBP, narrow pulse pressure, cool extremities, decreased Co2
~ subjective: thirst, anxiety
Shock
The younger the pt is…
The longer the body will try to compensate for
S/S of progressive stage of shock
↓ MAP - 20
Compensatory mechanism function but ↓ perfusion/oxygenation to vital organs
Hypoxia (vital organs) and Anoxia /ischemia (less vital organs)
= ↑ metabolites → Cell death occurs
S/S of progressive stage
Subjective
Objective
~subjective: impending doom, confusion, ↑ thirst
~ objective: ↑/ weak pulse, ↓ bp
pallor → cyanosis of mucosa/nailbeds
Labs of progressive stage
↓ blood pH
↑ lactic
↑ K+
↑ PaCo2 / pao2
If caused by dehydration: H&H ↑
Describe refractory/ mods stage
Too much cell death from ↓ perfusion / extensivee vital organ damage
Will not respond to tx
What position do we place patients in to ↑ perfusion
Semi fowlers
Medications for shock, what are the categories?
Vasoconstrictors
Iotropic agents
Drugs that enhance myocardial perfusion
What kind of vasoconstrictors do we use in shock
Norepinephrine (levophed)
Epinephrine (adrenaline)
Vasopressin (Pitressin)
What kind of inotropic agents do we use in shock?
Dobutamine / milirione
What kind of drugs do ul use to enhance myocardial perfusion?
Sodium nitroprosside
Nitroglycerin
- dilates coronary arteries
How often should he assess vitals
Q 15
Sepsis vs sepsis shock
Sepsis = mods
Sepsis shock = system inflammatory response syndrome
S/s of hypovolemia
↑ hr, ↓ bp, thready pulse, orthostatic hypotension, ↓ CVP, ↑ rr, hypoxia
Seizures can occur
Define sepsis shock
Infection + Widespread inflammation occurs
= systemic inflammatory response syndrome
= hormonal, tissue, vascular and oxidative stress
→ ↓Gas exchange / perfusion
Difference between
Innate response vs compensatory response
Innate: fever, leukocytosis/ leukopenia, left shift/bandemia
Compensatory: tachypnea, hypotension, altered loc = mods
S/S of sepsis shock
↓ bp, ↓ urine output,↑ rr
Temp changes based on duration of sepsis/ WBC function
Inappropriate clotting w/microthrombi formation
↑ toxic metabolites, ↑ inflammation
Define DIC
What is this a complication of?
Complication of sepsis
Fibrin and clotting factors are consumed, none are left causing bleeding
What are normal lactate levels?
1-2 = normal
>2 = sepsis
4-6-septic shock
Hemodynamic monitoring: CVPP
What does it stand for?
What are the levels
Central venous pressure
Normal: 2-8
Hypovolemic: <2
Hypervolemic: > 8
Define SIRS
Pro / anti inflammatory mediators released, causing them to fight each other and body attacks itself
Lab values during DIC
Decreased:
- ↓ serum fibrinogen
-↓platelets on CBC
Increased:
↑ d-dimer
↑ fibrin degradation products
↑ prothrombin time (pt)
↑ partial thromboplastin time (ptt)
What are clinical manifestations of bleeding during DIC
Petechia, ecchymoses, weeping wound sites
Bleeding mucous membranes (mouth, nose, ears, eyes)
What is an end stage s/s of hypovolemia?
Pale, cold clammy skin
In hemorrhagic shock, what “fluids” do we give?
PRBC’s
Clotting factors: FMP and Cryo
A change in one v/s in a 4-6 hr period =?
↑ sepsis risk
Why do all those lab levels change in DIC?
Clotting factors break apart and float in blood
What is the difference between primary and secondary assessment?
Primary: What needs to be taken immediately
• ABCDE
Secondary: anything else wrong but doesn’t need to be addressed immediately
What does ABCDE stand for?
Airway (confirm patent and c-spine is immobile)
Breathing (can place pt up to 6L w/o order)
Circulation (check all pulses, establish IV/IO access, consider blood order)
Disability (state GCS, pupil size/response)
Exposure (remove clothing, cover w warm blanket)
Objective vs subjective
Objective: what nurse evaluates (vital signs, assessment, pain scale)
Subjective: what pt feels
What does CVP monitor?
’ R atrial pressure (changes due to volume loss )
How to calculate Cardiac output
Stroke volume x hr (amount of blood in left ventricle)
Emergency nursing
Changes in pupils indicate what?
Construction: drug related
Dilation: drugs, brain injury, sever hypoxia
Unequal: brain swelling, head injury, blunt force trauma
Unreactive: brain injury and poor outcomes
Are pupils changing an early or late sign
Late sign in decompensating pt
Danger v/s emergency nursing
Age, hr, rr
<3m0, >180 bpm, > 50 RR
3m -3y, >160, 140 RR
3-8y, 140,> 30
8y, > 100, >20
What are the reversal of anticoagulants?
Vit k
Concentra
Prothrombin complex
Protamine
Praxablind
What are CVP levels?
Normal: 2-8
Hypervolemic: >8
Hypovolemic : 0-2
Heat exhaustion s/s
Flu like headache, weakness, N/V
Heat exhaustion tx
Community vs clinical
Community: stop activity, find cool place, drink water, remove tight clothes
Clinical: monitor v/s, rehydrate w/NS, draw electrolytes, may need admitted
Heat stroke S/S
Body temp >104-105
AMS (confusion, bizarre behaviors, seizures, coma)
↓BP, ↑ hr, ↑ rr, weak pulse
Weakness, hot/flushed dry skin
↓ NA+
Can cause cerebral edema/encephalopathy, brain hemorrhage then coma
Heat stroke Tx
Community vs clinical
Community: medical emergency, ensure airway, contact EMS, no food or liquid (aspiration risk)
Clinical: give O2, large bore IVs, NS rehydration, cooling blanket, labs, core temp (rectal/foley), check for elevated troponin and myoglobinuria
Emergency nursing
Primary survey
AIRWAY/ALERT (AVPU-Alert, Voice arousal, Pain arousal, Unresponsiveness)
Breathing (broken ribs/flail chest can affect this)
Circulation (palpable carotid, femoral and cap refills)
Disability (neuro status, GCS, PERRLA)
Eexposure
Emergency nursing
Secondary Survey
Needs attention after emergent condition
SAMPLE
Symptoms, Allergies, Meds, Past hx, Last oral intake, Evebts
Head to toe
Check/palpate head, drainage from eyes (CSF LEAK), chest, GI, extremities, log roll and check back
Color code
Red =?
Yellow =?
Green=?
Black =?
Red-emergent
Yellow- can wait for short time
Green= monurgent/walking wounded
Black= expected to die
Trauma centers
Level 1?
Large teaching hospitals
All trauma surgeon (Paeds/adults)
Conducts research for trauma verification
Trauma centers
Level 2 vs 3
both community hospitals
Level 2: provides care to most pt
Level 3: stabilizes pt with most injury then transfer
Trauma center
Level 4
Rural and remote
Basic trauma stabilization and ACLS
THEN TRANSFER IMMEDIATELY
Types of disasters
External vs internal
Internal: fire, explosion, loss of critical utilities, violence
External: earthquake, tornado, technology problems, viruses
