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Medsurg 2 > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Shock S/S
~Neuro

A

Early: anxiety, restlessness, increased thirst
Late: ↓ CNS (lethargy,) AMS, weakness, diminished/absent deep tendon reflexes, sluggish pupils

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2
Q

Shock S/Sx
~Cardiac:

A

↓ cardiac output,↓ bp
↑ hr
Thready/weak pulses, narrowed pulse pressure, decreased peripheral pulses
↓JVP, flat veins (neck, hand)
Slow cap refill

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3
Q

Shock S/S:
~respiratory

A

↑ rr
Shallow breathing
↓PaCo2 →↑
Cyanosis (nail beds /lips)

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4
Q

Shock S/S
~ gi

A

↓ motility
Diminished / absent bowel sounds
N/V/constipation

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5
Q

Shock S/S:
~GU

A

↓ urine output
↑ specific gravity
Sugar/acetone in urin

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6
Q

Shock S/S:
~skin

A

Cool → cold
Pale → mottled → cyanotic
Dry mouth
↓ cap refill

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7
Q

How to calculate MAP?

A

SBP+ 2 (DBP) and divide by 3

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8
Q

What happens to MAP during shock?

A

↓ due to ↓ total blood volume / cardiac output ( hr x stroke volume) and size/integrity of vascular bed

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9
Q

What level do we want the map to be?

A

> 65

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10
Q

What 3 things does hemorrhage lead to?

A

↓ venous return =↓ JVP
↓ bp
Hypovolemic shock → insufficient organ perfusion

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11
Q

What 2 things does trauma cause?

A

Hemorrhage
Third spacing of fluid

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12
Q

What 2 things happen w/ third spacing of fluid?

A

Hypovolemic shock
Ruptured vessels leaking into large cavities and ↑ inflammatory mediators

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13
Q

Insufficient organ perfusion
~ Brain

A

Cerebral hypoxia = progressive ↓ in LOC

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14
Q

Insufficient organ perfusion
~ cardiac

A

↓ bp =↑ hr
↓ myocardial contractility (from lactic acidosis) = PEA

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15
Q

Insufficient organ perfusion
~ kidneys

A

A renal perfusion
= renal ischemia = acute tubular necrosis = renal failure
↓ GFR = oliguria

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16
Q

Insufficient organ perfusion
~ skin

A

Body vasoconstricts - preserves circulation to vital organs
= cold mottled extremities

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17
Q

Insufficient organ perfusion
~ all body tissue

A

↓ lactate clearance (liver, kidneys, skeletal muscle)
= lactic acidosis

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18
Q

What are the 4 stages of shock?

A
  1. Initial stage
  2. Compensatory stage
  3. Progressive stage
  4. Refractory/MODS stage
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19
Q

Describe initial stage of shock
What is the alert?

A

↓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

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20
Q

Describe the compensatory stage of shock

A

↓ 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+

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21
Q

S/S shock
~ objective
~ subjective

A

~ objective: restlessness, ↑ hr/rr, ↑DBP, narrow pulse pressure, cool extremities, decreased Co2
~ subjective: thirst, anxiety

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22
Q

Shock
The younger the pt is…

A

The longer the body will try to compensate for

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23
Q

S/S of progressive stage of shock

A

↓ MAP - 20
Compensatory mechanism function but ↓ perfusion/oxygenation to vital organs
Hypoxia (vital organs) and Anoxia /ischemia (less vital organs)
= ↑ metabolites → Cell death occurs

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24
Q

S/S of progressive stage
Subjective
Objective

A

~subjective: impending doom, confusion, ↑ thirst
~ objective: ↑/ weak pulse, ↓ bp
pallor → cyanosis of mucosa/nailbeds

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25
Q

Labs of progressive stage

A

↓ blood pH
↑ lactic
↑ K+
↑ PaCo2 / pao2

If caused by dehydration: H&H ↑

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26
Q

Describe refractory/ mods stage

A

Too much cell death from ↓ perfusion / extensivee vital organ damage
Will not respond to tx

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27
Q

What position do we place patients in to ↑ perfusion

A

Semi fowlers

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28
Q

Medications for shock, what are the categories?

A

Vasoconstrictors
Iotropic agents
Drugs that enhance myocardial perfusion

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29
Q

What kind of vasoconstrictors do we use in shock

A

Norepinephrine (levophed)
Epinephrine (adrenaline)
Vasopressin (Pitressin)

30
Q

What kind of inotropic agents do we use in shock?

A

Dobutamine / milirione

31
Q

What kind of drugs do ul use to enhance myocardial perfusion?

A

Sodium nitroprosside
Nitroglycerin
- dilates coronary arteries

32
Q

How often should he assess vitals

A

Q 15

33
Q

Sepsis vs sepsis shock

A

Sepsis = mods
Sepsis shock = system inflammatory response syndrome

34
Q

S/s of hypovolemia

A

↑ hr, ↓ bp, thready pulse, orthostatic hypotension, ↓ CVP, ↑ rr, hypoxia
Seizures can occur

35
Q

Define sepsis shock

A

Infection + Widespread inflammation occurs
= systemic inflammatory response syndrome
= hormonal, tissue, vascular and oxidative stress
→ ↓Gas exchange / perfusion

36
Q

Difference between
Innate response vs compensatory response

A

Innate: fever, leukocytosis/ leukopenia, left shift/bandemia
Compensatory: tachypnea, hypotension, altered loc = mods

37
Q

S/S of sepsis shock

A

↓ bp, ↓ urine output,↑ rr
Temp changes based on duration of sepsis/ WBC function
Inappropriate clotting w/microthrombi formation
↑ toxic metabolites, ↑ inflammation

38
Q

Define DIC
What is this a complication of?

A

Complication of sepsis

Fibrin and clotting factors are consumed, none are left causing bleeding

39
Q

What are normal lactate levels?

A

1-2 = normal
>2 = sepsis
4-6-septic shock

40
Q

Hemodynamic monitoring: CVPP
What does it stand for?
What are the levels

A

Central venous pressure
Normal: 2-8
Hypovolemic: <2
Hypervolemic: > 8

41
Q

Define SIRS

A

Pro / anti inflammatory mediators released, causing them to fight each other and body attacks itself

42
Q

Lab values during DIC

A

Decreased:
- ↓ serum fibrinogen
-↓platelets on CBC

Increased:
↑ d-dimer
↑ fibrin degradation products
↑ prothrombin time (pt)
↑ partial thromboplastin time (ptt)

43
Q

What are clinical manifestations of bleeding during DIC

A

Petechia, ecchymoses, weeping wound sites
Bleeding mucous membranes (mouth, nose, ears, eyes)

44
Q

What is an end stage s/s of hypovolemia?

A

Pale, cold clammy skin

45
Q

In hemorrhagic shock, what “fluids” do we give?

A

PRBC’s
Clotting factors: FMP and Cryo

46
Q

A change in one v/s in a 4-6 hr period =?

A

↑ sepsis risk

47
Q

Why do all those lab levels change in DIC?

A

Clotting factors break apart and float in blood

48
Q

What is the difference between primary and secondary assessment?

A

Primary: What needs to be taken immediately
• ABCDE
Secondary: anything else wrong but doesn’t need to be addressed immediately

49
Q

What does ABCDE stand for?

A

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)

50
Q

Objective vs subjective

A

Objective: what nurse evaluates (vital signs, assessment, pain scale)
Subjective: what pt feels

51
Q

What does CVP monitor?

A

’ R atrial pressure (changes due to volume loss )

52
Q

How to calculate Cardiac output

A

Stroke volume x hr (amount of blood in left ventricle)

53
Q

Emergency nursing
Changes in pupils indicate what?

A

Construction: drug related
Dilation: drugs, brain injury, sever hypoxia
Unequal: brain swelling, head injury, blunt force trauma
Unreactive: brain injury and poor outcomes

54
Q

Are pupils changing an early or late sign

A

Late sign in decompensating pt

55
Q

Danger v/s emergency nursing
Age, hr, rr

A

<3m0, >180 bpm, > 50 RR
3m -3y, >160, 140 RR
3-8y, 140,> 30
8y, > 100, >20

56
Q

What are the reversal of anticoagulants?

A

Vit k
Concentra
Prothrombin complex
Protamine
Praxablind

57
Q

What are CVP levels?

A

Normal: 2-8
Hypervolemic: >8
Hypovolemic : 0-2

58
Q

Heat exhaustion s/s

A

Flu like headache, weakness, N/V

59
Q

Heat exhaustion tx
Community vs clinical

A

Community: stop activity, find cool place, drink water, remove tight clothes
Clinical: monitor v/s, rehydrate w/NS, draw electrolytes, may need admitted

60
Q

Heat stroke S/S

A

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

61
Q

Heat stroke Tx
Community vs clinical

A

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

62
Q

Bee stings Tx/signs

A

Tx: epi injector and epi IM
S/S: sob, hires, anaphylaxis

63
Q

Beesting heath maintenance

A

Always carry epic pen, wear medical alert bracelet

64
Q

Drowning tx
Community vs clinical

A

Community: remove from water, spine stabilization, airway clearance, prevent Vfib, dry pt before placing defibrillator
Clinical: patent IV, resuscitation, CPR, gastric compression

65
Q

Emergency nursing
Primary survey

A

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

66
Q

Emergency nursing
Secondary Survey

A

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

67
Q

Color code
Red =?
Yellow =?
Green=?
Black =?

A

Red-emergent
Yellow- can wait for short time
Green= monurgent/walking wounded
Black= expected to die

68
Q

Trauma centers
Level 1?

A

Large teaching hospitals
All trauma surgeon (Paeds/adults)
Conducts research for trauma verification

69
Q

Trauma centers
Level 2 vs 3

A

both community hospitals
Level 2: provides care to most pt
Level 3: stabilizes pt with most injury then transfer

70
Q

Trauma center
Level 4

A

Rural and remote
Basic trauma stabilization and ACLS
THEN TRANSFER IMMEDIATELY

71
Q

Types of disasters
External vs internal

A

Internal: fire, explosion, loss of critical utilities, violence
External: earthquake, tornado, technology problems, viruses

Medsurg 2 (7 decks)

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