Exam 3: Shock, Sepsis, Respiratory Flashcards
What is Hypovolemic shock?
Impaired tissue perfusion resulting from severely diminished circulating volume.
Loss of intravascular fluid volume.
What is the difference between absolute and relative hypovolemic shock?
- Absolute hypovolemia: fluid is lost via hemorrhage, GI loss, drainage, diuresis or diabetes insipidus.
- Relative hypovolemia: internal, extravascular loss into interstitial or intracavitary space (third spacing).
Hypovolemic symptoms?
Hypotension, tachycardia, anasarca, ascites
Decreased blood flow to the heart, because the volume is in the periphery or in cavities or it has let the body
Why are they tachypnea: they are trying to oxygenate the tissues, compensate
Urine output would be diminished: potassium , sodium, creatine
Anxiety, restlessness, confusion: because brain is not being oxygenated
Flat neck veins because there is no volume to fill them: will not see jugular vein distention on these patients
What is cariogenic shock?
Systolic or Diastolic dysfunction result in compromised Cardiac Output (CO). Pathophysiology: -Myocardial Infarction (MI) -Structural Problem -Arrhythmia
-Results in impaired tissue perfusion and impaired cellular metabolism
Symptoms of cariogenic shock?
What will they look like: low BP, fast HR, the harder the heart works the higher the oxygen demand is, high RR.
Pulmonary congestion: crackles in lungs because fluid cant move forward because of insufficient pump
Neck vein distention
What labs are you looking for? Troponin, BNP, potassium, CRP, sodium, potassium, BUN, creatine
Give lasixs to get rid of some of the fluid so the heart doesn’t have to work so hard!!! ON test !!
What is Distributive Shock ?
Blood volume is not lost but is distributed to the interstitial tissues where it cannot circulate and deliver oxygen
Caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, capillary leak
Neural-induced distributive shock
Chemical-induced distributive shock
(Dilate out , a lot of fluid could cause capillary leak
Chemical induced: loss of vascular tone, what would happen in your lungs?… you would fill up with fluid and drown immediately
)
What is vasogenic shock?
Impaired tissue perfusion resulting from damage or dysfunction of the sympathetic nervous system.
-This type of shock is uncommon, and may be associated with trauma, anesthesia, spinal shock.
Occurs following spinal cord injury at T5 or above.
-Results in massive, uncompensated vasodilatation due to the loss of SNS vasoconstrictor tone.
Symptoms of vasogenic shock?
Bradycardic,
Placeothermia: taking on the temp of their surronding
Nausea, vomiting, decreased urine output
- Profound Hypotension, narrow pulse pressure
- The parasympathetic nervous system is activated and un-opposed resulting in bradycardia
- SVR, PAOP, CVP, CO
- Pulmonary dysfunction related to level of injury
- Poikilothermia, absence of sweating
*Anxiety, restlessness, confusion
Nausea, vomiting, decreased urine output
What is anaphylactic shock?
- Impaired tissue perfusion resulting antigen-antibody reaction releasing histamine into the bloodstream.*
- May be caused by contrast media, drugs, blood transfusions, food allergies, insect stings, snake bites.
- Capillary permeability increases, arteriolar dilation occurs.
- Blood return to the heart decreases dramatically
Misc. anaphylactic shock info
Impaired tissue perfusion resulting antigen-antibody reaction releasing histamine into the bloodstream.
May be caused by contrast media, drugs, blood transfusions, food allergies, insect stings, snake bites.
Capillary permeability increases, arteriolar dilation occurs.
Blood return to the heart decreases dramatically
True or false
Zyrtec works as well as an epi-pen
True
Anaphylactic shock symptoms
- Hypotension, narrow pulse pressure
- SVR, PAOP, CVP, CO
- Stridor, tachypnea, wheezing
- Hives, itching, flushed warm skin
- Anxiety, restlessness, confusion, seizures
- Nausea, vomiting, diarrhea, abdominal cramping
What is obstructive shock?
- Caused by problems that impair the ability of the normal heart muscle to pump effectively
- Heart is normal, but conditions outside the heart prevent either adequate filling of the heart or adequate contraction of the healthy heart muscle
- Pericarditis, Cardiac tamponade
Uniqueness of obstructive shock
Not cardiogenic shock because the heart is normal, its something outside the heart causing the problem
Cardiac tamponade: fluid in the pericardium causes the ventricles to not be able to fill
Pericarditis is another example of obstructive shock
Stages of shock
- Initial stage (early shock)
- Nonprogressive stage (compensatory stage)
- Progressive stage (intermediate stage)
- Refractory stage (irreversible stage)
Initial stage of shock
- Initial stage may not be clinically apparent.
- Metabolism begins to shift from aerobic to anaerobic.
- Lactic acid (removed via the blood and broken down in the liver) accumulates.
- Oxygen needs increase while oxygen availability decreases.
(Metabolism goes from Using oxygen to not using oxygen
Product of anaerobic met. Is lactic acid
Lactic acid starts to accumulate!!! ON TEST!
)
Nonproggressive stage of shock
- Compensatory mechanisms are activated to overcome sequelae of anaerobic metabolism and to maintain homeostasis.
- Neural, hormonal, and biochemical compensatory mechanisms are activated.
- Clinical presentation demonstrates the imbalance of oxygen supply and demand.
- Initial finding: Hypotension
- Neural compensation: SNS responds to the decrease in cardiac output (hypotension).
- Epinephrine and Norepinephrine are released.
- Blood flow is shunted to the most vital organs.
(Kidneys get activated the baroreptors release renin, adh, aldosterone, ephnephrine, nor-epinephrine…why do they release all of that….vasoconstriction, trying to save sodium to retain fluid, to keep bp up and homeostasis, and conserve water
Lactic acid comes too
If you recognize this early enough you can reverse the process
Notice the trend that your patient is hypotensive, decrease in cardiac output
Blood flow is shunted to the heart, brain, lungs, the gut
)
Progressive stage of shock
- This stage begins as the compensatory mechanisms fail.
- Capillary permeability increases, allowing fluid and proteins to leak from the intravascular space into the interstitial space. (Third spacing, Anasarca)
- Circulating volume is depleted.
Fun facts about shock
In cardiogenic shock you do not wanna give fluid, what if they are hypotensive and the doctor orders lasix…after administering the med their bp might drop more but after getting rid of the fluid their bp might come back up …it is ok to give diuretics
What makes neurogenic shock unique?
Neurogenic Shock: their pulse will be low, bradycardia …that’s what’s unique about neurogenic..usually pulse is high in shock
Progressive stage of shock: pulmonary
- Pulmonary arteriolar constriction
- Pulmonary capillary leak
- Alveolar edema and decreased surfactant
- Vasoconstriction and bronchoconstriction
- Tachypnea, crackles, increased work of breathing
- Likely to develop ARDS
Crackles in the lungs, they will get harder and harder to oxygenate
Surfactant helps keep alevoli inflated and the right degree of moistness
Disseminated intravascular coagulation…..ON TEST!!! Know what it is
??
Refractory stage of shock
- The final stage*
- Profound hypotension and hypoxemia
- Multisystem organ failure
- Recovery is very unlikely
Diagnostic studies for shock
Labs: CBC, Hgb, Hct, WBC, DIC Screen Electrolytes, BUN, Creatinine, --Liver panel -ABG, Lactate -Blood cultures -Chest x-ray -12 Lead ECG
Trend of the labs;
Platelets, INR, HgB, Hematocrit, D-dimer (used for DVT and pulmonary embolus, important in looking at coagulation…ON TEST)
Collaborative Care: Fluid Resuscitation for shock
**Cardiogenic shock is the exception here
Crystalloids vs. Colloids debate
Replace to goal CVP, PAOP, or UO
Monitor pulmonary status
Monitor for compartment syndrome
Consider vasoactive drugs (continuous infusion)
Crystalloids vs colloids
Crystalloid …normal saline for anyone who needs fluid resuscitation
Colloids tend to make platelets slippery
If patients hemoglobin is low and you give them more fluids you may lower hemoglobin further, so check hemoglobin when giving fluid, might need some RBCs
Collaborative Care: Drug Therapy for shock
- Vasoactive agents
- Sympathomimetic agents
- Vasodilator agents
Levophed is the primary choice
Dopamine is the sedond choice
Both are vasoactive , clamp down and constrict
Dobutamine
- inotrope
- squeezes ventricles, makes you have a better contraction which gives you better cardiac output
What is SIRS?
**Systemic inflammatory response to an insult (infection, injury, ischemia, infarct)
- Inflammatory cells are activated causing the release of mediators, damage to endothelium, and hypermetabolism.
- Vasodilatation and capillary permeability
- Phagocytation of foreign debris occurs and the coagulation cascade is activated.
True of false
In acute respiratory failure the patient is always hypoxemic
True
What is ventilatory failure?
- Physical problem of the lungs or chest wall
- Defect in the respiratory control center in the brain
- Poor function of the respiratory muscles, especially the diaphragm
- Extrapulmonary causes
- Intrapulmonary causes
Examples of Intrinsic lung failure
- Large Airway Obstruction
- Bronchial disease
- Parenchymal disease
- Vascular disease
Examples of Extrinsic ventilatory failure
- Disease of the plea and chest wall
- Disorders of the respiratory muscles
- Disorders of the peripheral nerves
- Disorders of the CNS
What does surfactant do?
- Lowers surface tension
- Increases lung compliance
- Provides for stability and even alveolar inflation
- Prevents pulmonary edema by keeping the alveoli dry
What is oxygenation failure?
Thoracic pressure changes are normal, and air moves in and out without difficulty but does not oxygenate the pulmonary blood sufficiently
Symptoms of oxygenation failure
- Ventilation is normal, but lung perfusion is decreased
- Impaired diffusion of oxygen at the alveolar level
- R to L shunting of blood
- V/Q mismatch
- Low partial pressure of O2
- Abnormal hemoglobin
What is the Oxy-hemoglobin Dissociation Curve?
??
What is Combined Ventilatory and Oxygenation Failure
A combination of ventilatory and oxygenation failure that often occurs in patients who have abnormal lungs such as those with chronic bronchitis or emphysema or during asthma attacks
Diseased bronchioles and alveoli cause oxygenation failure, and the work of breathing increases until the respiratory muscles are unable to function effectively, causing ventilatory failure
What happens in acute lung injury?
Normal alveoli: Gas exchange: O2 and CO2
Macrophage: Infection control
Cytokines: alert to an “intruder in the body”, cause neutorphil activation which causes cellular destruction and fluid is released , base gets damaged and surfactant gets denatured, protein flows out, whne protein flows out other things come out with it i.e. water and because the macrophage sent out cytokines, leukokines come out to play, all this is happening in the alveolus, phagocyte comes and cleans everything up , protein blob gone, things then get repaired but everything is fibrotic afterwards. People recover but their lungs are always scared and fibrotic
What is a flail chest?
Two or more ribs are broken, each in at least two places; or a fracture or separation of the ribs from the breastbone producing a free-floating segment. The area between the fractures move in the opposite direction of the rest of the chest when breathing. This segment is called the “flail area.”
What do you do for fractured ribs/flail chest?
Splint when coughing, pain medications, incentive spirometer
What is a Pneumothorax?
Pneumothorax: air in the pleural space
Chest trauma and thoracic injuries
Tracheal deviation causes decreased cardiac output because of mediatnal shift
What is a Bi-PAP?
??
What is ARDS?
Acute respiratory distress syndrome?
- Hypoxia that persists even when oxygen is administered at 100%
- Decreased pulmonary compliance
- Dyspnea
- Noncardiac-associated bilateral pulmonary edema
- Dense pulmonary infiltrates seen on x-ray
Patient Gets harder and harder to ventilate, resistant to oxygenation
What are causes of lung injury in ARDS?
- Systemic inflammatory response is the common pathway
- Intrinsically, the alveolar-capillary membrane is injured from conditions such as sepsis and shock
- Extrinsically, the alveolar-capillary membrane is injured from conditions such as aspiration or inhalation injury
Diagnosing ARDS
- Lower PaO2 value on arterial blood gas
- Refractory hypoxemia
- “Whited-out” appearance to chest x-ray
- No cardiac involvement on ECG
- Low to normal PCWP
ARDS interventions
- Endotracheal intubation and mechanical ventilation with positive end-expiratory pressure or continuous positive airway pressure
- Drug and fluid therapy
- Nutrition therapy
Types of ventilators
- Negative-pressure ventilators
- Positive-pressure ventilators:
- Pressure-cycled ventilators
- Time-cycled ventilators
- Volume-cycled ventilators
Modes of ventilation
- Assist-control ventilation (AC)
- Synchronized intermittent mandatory ventilation (SIMV)
- Bi-level positive airway pressure (BiPAP)
Mechanical ventilation complications
- Lung complications:
- Barotrauma
- Volutrauma
- Cardiac complications:
- Hypotension
- Fluid retention
- Valsalva maneuver
Extubation
Weaning and extubation
Hoarness is normal but stridor is not because they get rebound swelling
Aspiration, level of consciousness, bp and RR
Make sure they can manage their own secretions, aspiration often happens at extubation
Can you cure chronic illness?
Chronic illness can be managed but not cured
True or false
80% of adults 65 yrs of age or older have one or more chronic illnesses
True
Chronic vs. acute illness
- *Acute**
- Onset sudden
- S/S are related to disease/condition itself
- Alter normal routine pattern for a short time
- Has a predictable end
- Life returns to premorbid
- *Chronic**
- Onset varies; may be sudden or slow
- S/S often difficult to associate with disease
- Alters normal routine indefinitely, perhaps for a lifetime
- No predictable end
- Becomes an identity
Goals of rehabilitation
- Prevention of injury
- Restoration of function
- How does this differ for someone 5 years old vs someone 85 years old?????
- Compare and contrast rehabilitation in the home vs rehabilitation as inpatient.
- What are some types of inpatient and outpatient facilities?
What is the CATs scale?
??
Regualtions on chronicity
Americans with Disabilities Act – 1991
In long term facilities, federal regulations require that residents not lose their functional skills (restorative nursing)
What are two main nursing DX for chronic illness?
Nursing DX: Ineffective coping, caregiver role strain are two main DX for chronic illness
True or false
The four main types of noncommunicable diseases are cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes.
True
What is the ADA?
The Americans with Disabilities Act of 1990 (ADA) prohibits discrimination and ensures equal opportunity for persons with disabilities in employment, State and local government services, public accommodations, commercial facilities, and transportation. It also mandates the establishment of TDD/telephone relay services. The current text of the ADA includes changes made by the ADA Amendments Act of 2008 (P.L. 110-325), which became effective on January 1, 2009. The ADA was originally enacted in public law format and later rearranged and published in the United States Code.
What are peripheral vascular risk factors?
Risk factors that cannot be changed include the following:
Age : over 45
History of heart disease
Diabetes mellitus (type 1 diabetes)
Gender : Male
Postmenopausal women
Family history of dyslipidemia, hypertension, or PV disease
Peripheral vascular risk factors that can be changed?
Risk factors that may be changed or treated include:
- Coronary artery disease
- Impaired glucose tolerance
- Dyslipidemia
- Hypertension
- Obesity
- Physical inactivity
- Smoking or use of tobacco products
What is the pV assessment?
P-Pulses. feel the most distal pulse possible on the assigned limbs BILATERALLY, this is a comparative assessment!.
M- Mobility is assessed by simply asking a person to move the limb or observing spontaneous movement.
S-Sensation. Elicit patient response to touch of the distal part of the extremity.
C-Color OR Capillary refill to assess perfusion. Look for pallor, cyanosis, pinkness etc.
T-Temperature can be assessed when sensation is being tested.
PMS Causes Tension
Types of edema
*around the eye its periorbital edema
In the eye is scleral edema
*anasarca is edema all over the body
What is the ankle brachial index?
?/
What do we do for people with a pulmonary emboli?
oxygenation, anti-coagulants
DVT pain
DVT: venous so pain comes on more slowly
What are varicose veins?
Varicose veins are irregular, tortuous veins with incompetent valves
Varicose veins: valves are incompetent
People who stand a lot are prone to get VV: surg techs, OR nurses
Use teds socks, elevate feet when sitting
True or false
Marfan syndrome is a risk factor for cardiovascular disorders.
True
True or false
Renal failure is a complication of AAA repair caused by blood loss or clips applied above to the aneurysm, which may interfere with renal artery perfusion.
True
True or false
Cold, mottled extremities are indicative of occlusion, which could lead to gangrene.
True
True or false
Heparin-induced thrombocytopenia, an immune disorder, presents with platelets less than 150,000.
True
