Exam 1, Deck 3 Flashcards
Shock (def)
Generalized inadequate circulation
What happens to electrolytes during shock?
K+ rushes out of the cell
Na+ and water rush into cell (cellular edema)
Result of cellular edema (4)
- Fluids and electrolytes move more freely, Na+ pump impaired
- Cell damage and death
- Lysosomal membrane rupture
- Mitochondrial damage
3 types of shock:
Hypovolemic
Cardiogenic
Distributive / Circulatory
Hypovolemic shock - what is happening?
Loss in circulating volume (Heart is still working)
Cardiogenic shock - what is happening?
“Pump failure” - there may be adequate blood, but it’s not being pumped where it needs to go
Disruptive / circulatory shock: What is happening?
“Massive Vasodilatation”
3 types of disruptive / circulatory shock
- Neutrogenic
- Anaphylactic
- Septic
3 causes of neutrogenic shock
- Spinal cord injury
- Spinal anesthesia
- ADEs
3 causes of anaphylactic shock
- Med allergy
- Bee sting
- Blood transfusion reaction
Two causes of septic shock
- Systemic infection
- Uncontrolled pneumonia
Vital signs of a client in shock: Compensatory
- RR
- HR
- BP
RR: >20/min
HR: >100/min
BP: WNL
Vital signs of a client in shock: Progressive
- RR
- HR
- BP
RR: Rapid, shallow
HR: >150/min
BP: Systole <80
Vital signs of a client in shock: Irreversible
- RR
- HR
- BP
RR: Intubated
HR: Erratic
BP: Requires support
Mental status of a client in shock:
- Compensatory
- Progressive
- Irreversible
- Compensatory: Restless
- Progressive: Lethargy
- Irreversible: Unconscious
Urine output of a client in shock:
- Compensatory
- Progressive
- Irreversible
- Compensatory: Decreasing
- Progressive: <30cc/hr
- Irreversible: Anuria
Skin changes of a client in shock:
- Compensatory
- Progressive
- Irreversible
- Compensatory: Cold, clammy
- Progressive: Mottled, gray
- Irreversible: Jaundiced
Acid / base of a client in shock:
- Compensatory
- Progressive
- Irreversible
- Compensatory: Respiratory alkalosis
- Progressive: Respiratory and metabolid acidosis
- Irreversible: Profound acidosis
What is going on with compensatory shock (sum it up - 1 word)
HYPOXIA
What is going on with progressive shock (sum it up - 1 word)
HYPOINFUSION
of all symptoms
What is going on with irreversible shock? (sum it up - one word)
DEATH
Three things you do assess with a patient in shock:
1) VITALS: Check RR & HR often
2) Check for orthostatic hypotension
3) Assess for changes in LOC
When does cellular damage occur with shock?
BEFORE blood pressure begins to drop
Respiratory Sxs of a patient in progressive shock (4)
- Shallow, rapid respirations
- Crackles 2/2 PE
- Decreased O2 levels (hypoxic)
- PaCO2 levels increase (hypercapnic)
Cardiac Sxs of a patient in progressive shock (5)
- HR increases to 150 bpm
- Arrhythmias (2/2 hypoxemia)
- Ischemic changes (on ECR)
- Chest pain * MI
- BP dropping
Neurologic Sxs of a patient in progressive shock (4)
- Confusion
- Lethargy
- LOC
- Dilated pupils
Kidney Sxs of a patient in progressive shock (3)
- Decreased perfusion leads to decreased GFR –> acute renal failure
- Oliguria (<30mL/hr)
- Increased BUN and Creatinine
Liver Sxs of a patient in progressive shock (3)
- Enzymes rise
- Decrease ability to metabolize meds and waste products
- JAUNDICE
GI Sxs of a patient in progressive shock (2)
- Ulcers
- Bleeding
Priorities for a patient in shock (2)
1) Limit further damage
2) Improve cardiac function:
- -> improve blood sully
- -> Decrease oxygen demand
Shock: Position of patient
Modified trendelenburg: Torso is flat, legs are elevated 20-40*
Shock: IVs (2)
- Blood products
- Isotonic r most likely to stay intravascular
Comfort for a shock patient
DO NOT ADD BLANKET – would increase peripheral vasodilatation and further drop BP
Why do you put a shock patient on bedrest?
To decrease BMR
Why are shock meds given IV?
Because of poor perfusion to muscles and GI tract
Two goals of shock meds:
1) Maintain (or increase) CO
2) Decrease cardiac workload
Two meds that work together to maintain CO and decrease cardiac workload (for shock)
Adrenergic
Vasodilator
Adrenergics given for shock (2)
Dobutamine or dopamine
Function of adrenergics in shock (3)
- Increase CO
- Vasoconstriction increases afterload
- Increased myocardial contractility
Vasodilator given for shock
Nitroglycerine
Functions of Nitroglycerine in shock (3)
- Decrease preload and afterload
- Decrease workload of the heart
- Overall: DECREASE OXYGEN DEMAND
Overall effect of Adrenergic + Vasodilator (Shock) (4)
- Increased CO
- Minimizes cardiac workload
- Vasodilitation (increased blood flow to myocardium)
- Increased O2 delivery to heart
Besides Dobutamine and Dopaimine, four other adrenergics given for shock
- Norepinephrine (Levophed)
- Epinephrine
- Phenylephrine
- Antiarrhythmic meds
What IV solution do you administer to a patient in shock? Why (2)?
NORMAL SALINE.
- Isotonic more likely to stay intravascular
- If you give blood products, glucose causes clotting.
Monitoring device for shock
“Swan Ganz Catheter” (Right heart catheter)
Where should monitor device be inserted
And why not in the other placei t could go
Intrajugular
Could be subclavian, but risk puncturing lung
Shock complications: Respiratory
“Shock Lung” / “Adult Respiratory Distress Syndrome”
What is ARDS
Adult Respiratory Distress Syndrome
- Increasing capillary permeability leads to fluid seeping around lungs
How do you know if a patient has ARDS
PaO2 keeps dropping even as you increase oxygen
Shock complications: Organs
- Multiorgan complication
- Four affected symptoms
Multiple Organ Dysfunction Syndrome (MODS)
- Renal failure
- GI bleed
- Lungs
- Liver
What comprises the upper respiratory?
Nares to trachea
What comprises the lower trachea?
Carina to alveoli
Where is the carina?
At the angle of Louis
How do you know if you have intubated too far?
Breath sounds on the right side but none on the left – pull back
Decreased _______ is a factor in ARDS
surfactant
Where is anatomical dead space? How big is it?
- Everything respiratory that is not alveoli
- 1mL of anatomical dead space per pound of person
Flaring of nostrils: Late or early sign of respiratory distress?
- Late sign in an adult
- Early sign in a baby
Mouth breathing: Early or late sign of respiratory distress?
- Usually more of a late sign
What is “Negative Inspiratory Force?” What is normal NIF (#)?
Force a patient must be able to generate in order to respirate.
Normal NIF = - 60
Resistance of airways is determined by
DIAMETER
Three problems that narrow airways (and how)
Asthma (bronchoconstriction) Bronchitis Mucus) Foreign bodies (Obstruction)
What is the difference between dyspnea and shortness of breath?
Dyspnea = air hunger
Shortness of breath = Breathlessness; often high CO2
Hemoptysis (def)
Blood in sputum)
Early signs of hypoxia (3)
- Restlessness
- Change in LOC
- Change in RR
Late sign of hypoxia
- Cyanosis
What is Stridor? What does it indicate?
- High pitched lung sound
- Indicates major obstruction
MEDICAL EMERGENCY
Chest pain is fairly uncommon in respiratory disease except as a late sign – but what could it indicate? (3)
Pleurisy
Bad pneumonia
Pulmonary embolism
What does a Chest X Ray show?
Shows dense tissues: Tumors, foreign bodies, fluid
What is a CAT scan? What can it view
X rays in succession - can view tumors
3 assessments post- bronchoscopy
- Assess ABGs
- Gag reflex
- Dysphagia
How does a lung scan work
“Ventilation perfusion scan” – patient inhales radioactive isotopes (indicates clot to ung, pumonary emboli)
Indications for a spirometry machine
- Diagnosis of asthma or COPD
What can be observed with a spirometery machine (2)
Disease progression
Efficacy of treatment
What oxygen mask enables the highest % of O2?
Non-rebreather mask
What oxygen mask enables the most precise oxygen delivery?
Venturi Mask
How does respiration on a PEEP ventilator differ from normal respiration?
With a PEEP, pressure is still positive at the end of respiration
Benefits of PEEP
1) Prevents alveolar collapse
2) Effective dose of O2 can be lower
3) O2 administered at inspiration and expiration
What does an incentive spirometer prevent (2)
- Atelectasis (closing alveoli)
- Pneumonia
When should you never do percussion / vibration?
Immediately post-op
Two breathing excescises
- Diaphragmatic breathing
- Pursed lips breathing
What does pursed lips breathing?
Extends the length of exhalation
Why should you provide humidity for a patient receiving respiration assistance
- Helps keep secretions loose
- Patient with trach lost mechanical aid of nose and mouth to hydrate air.
COPD is an umbrella term for (2)
Emphysema, chronic bronchitis
Risk factors for COPD (3)
- Cigarette smoking
- Air / environmental pollution
- Alpha1-antitrypsin deficiency (genetic)
What is alpha1-antitrypsin?
Protein that helps protect lungs
Emphasema (def)
A slowly progressive disease characterized by destruction of the alveoli
What is the pathophysiology of COPD? (3)
- Lung elasticity is lost
- Alveoli destroyed
- CO2 retained
Two hallmark COPD symptoms
- Shortness of breath
- Shallow cough
Cor pulmonale (def)
Right ventricle increases pumping power to overcome pulmonary hypertension
(leads to hypertrophy, failure)
Three VISIBLE signs an examiner may see on a COPD patient
- Barrel chest
- Clubbing fingers
- Weight loss
Changes with breathing for a COPD patient (5)
- Shortness of Breath
- Chronic productive cough
- Prolonged expiration
- Expiratory wheezes
- Increased RR
What is the prime focus with treating a COPD patient?
IMPAIRED GAS EXCHANGE
Two things a COPD patient can do to improve symptoms
- Stop smoking
- Drink 2-3L of fluid a day
Type of treatment for mild COPD
Short acting bronchodilators
Type of treatment for moderate COPD
long acting bronchodilators
+ short acting bronchodilators for breakthrough sxs
Type of treatment for severe / very severe COPD
STEROIDS
+ long acting bronchodilators
+ short acting bronchodilators for breakthrough sxs
Purpose of bronchodilators (3)
- Relieve bronchospasm
- Reduce airway obstruction
- Increase O2 distribution
Three types of bronchodilators:
- Adrenergic
- Anticholinergics
- Methylxanthine
Two types of Adrenergic Bronchodilators:
- B2 Selective short-acting (acute)
- B2 Selective long-acting (daily mx)
B2 Selective Short acting - Prototype
When used
Albuterol
acute exacerbation
B2 Selective Long acting prototype (2 drugs)
When used
Formoteral
Salmeterol
(daily maintenence)
Anticholinergic: Prototype
(+ 2 other drugs)
(When used)
Atropine
(Atrovent, Spiriva)
(daily maintenence)
Methylxanthines (2 drugs)
When used
Aminophylline
Theophylline
Indication of corticosteroids
Anti-inflammatory
When would a patient be on daily corticosteroids?
If they have very advanced or acute COPD
Corticosteroid daily maintenence drug
Flunisolide (aerobid)
Corticosteroid acute exacerbation drug
Prednisone (methylprednisone) – SYSTEMIC
It is always OK to give COPD patients…
2-3 L nasal canula O2
Pulmonary Function Test: What is it measuring?
Compares Forced Expiratory Volume with Forced Vital Capacity
measures severity of COPD
FEV def
How fast the air in lungs can be moved out in 1,2 and 3 seconds
FVC def
How much air volume can be moved in and out of the lungs
Three sxs of chronic bronchitis
- Excessive mucus secretions
- Cough
- Dyspnea
Bronchits: Diagnostic criteria
- Episode lasting 3+ months in 2 consecutive years
Two causes of chronic bronchitis
- Recurrent lower RT infections
- Smoking (#1 cause)
Asthma: Def
Chronic REVERSIBLE inflammatory disease of the airways
Three sxs of asthma
- Bronchoconstriction (hyperresponsive airways)
- Swelling of mucosal lining
- Thick secretions
Four things that are released during an asthma attack
- Histamine
- Bradykinin
- Prostaglandins
- Leukotrienes
Respiratory rate of an asthmatic patient (and implications)
- Increased RR to blow off CO2
When they start retaining CO2 instead, patient is exhausted –> Respiratory distress
When should you be concerned with an asthmatic patient?
If they go into respiratory acidosis
Long acting bronchodilators for asthma (4)
ALL FOR DAILY MAINTENANCE
- Mast cell stabilizers
- Adrenergic Beta 2 agonist
- Methylxanthines
- Leukotriene inhibitors
Define Status asthmaticus
When treatment isn’t working for 24+ hours
Mast cell stabilizer – prototype
Cromolyn (Intal)
Adrenergic Beta 2 – prototype
Formoteral (Foradil)
Methylxanthines Prototypes (2)
Aminophylline
Theophylline
Leukotriene inhibitors - prototype
Xarfirlukast (Accolate)
Are you going to ace this exam
fuck yeah
