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NURSING > MED SURG II - SHOCK > Flashcards

MED SURG II - SHOCK Flashcards

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1
Q

Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism

A

Shock

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2
Q

Clinical manifestations of General Shock: Cardiac

A

Tachycardia
Hypotension
Decreased Cap Refill
Weak/Thready Pulses

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3
Q

Clinical manifestations of General Shock: Respiratory

A

Tachypnea

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4
Q

Clinical manifestations of General Shock: Renal

A

Decreased UOP

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5
Q

How does the skin look in the early stages of shock?

A

White

Ashen/Gray (darker skin tones)

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6
Q

Clinical manifestations of shock: Neurologic

A

Increased Anxiety, Agitation, and Confusion

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7
Q

Clinical manifestations of shock: GI

A

Decreased peristalsis
Decreased bowel sounds
can lead to ileus (later)

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8
Q

Shock: BUN and Creatinine

A

Increased

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9
Q

Shock: LFTs

A

Increased

Liver is not perfusing

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10
Q

Shock: Lactic Acid

A

Increased r/t metabolic acidosis

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11
Q

What is normal Lactic Acid?

A

< 2

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12
Q

Stage of Shock: Usually not clinically visible

Body is switching from aerobic to anaerobic metabolism

A

Initial

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13
Q

Stage of Shock: Body activates compensatory mechanisms to overcome increasing effects of anaerobic metabolism.

A

Compensatory

This is where we want to stop the progression of shock

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14
Q

Patient presents with: Tachycardia, Tachypnea, Slight Hypotension, Subtle MS Changes ….. what stage of shock?

A

Compensatory

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15
Q

Stage of Shock: Compensatory mechanisms fail

A

Progressive

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16
Q

Patient has marked changes in mental status and decreased peripheral perfusion…. what stage of shock?

A

Progressive

decrease in coronary, cerebral*, and peripheral perfusion

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17
Q

Stage of Shock: Profound hypotension and hypoxemia; recovery unlikely

A

Refractory

Signs of MODS

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18
Q

Primary nursing intervention for patient experiencing shock

A

OXYGEN

15L 100% non-rebreather

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19
Q

After giving Oxygen what is the next intervention?

A

Fluids

Increase Volume

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20
Q

What types of shock are fluids contraindicated in?

A

Cardiogenic and Neurogenic

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21
Q

What medications are given to a patient experiencing shock?

A

Vasopressors

Vasodilators

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22
Q

Examples of Vasopressors

A 
Levophed (norepinephrine)
Dobutamine
Pitressin
Epinephrine
Dopamine
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23
Q

After giving medications, what is the next nursing intervention for a patient experiencing shock?

A

Nutrition

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24
Q

What is the preferred route of nutrition for a patient experiencing shock?

A

Enteral

Ex: Tube feeding

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25
Q

What type of shock:

Systolic or diastolic dysfunction resulting in reduced CO and SV

A

Cardiogenic

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26
Q

What is CO? What is normal?

A

Volume in liters pumped by the heart in 1 minute

4-8L

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27
Q

What is SV? What is normal?

A

Volume in mL ejected per beat

60-120mL

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28
Q

Causes of Cardiogenic Shock

A 
*MI*
HF
Cardiomyopathy
Dysrhythmias
Valve Disorders
Ventricular Hypertrophy
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29
Q

What is unique about a patient in Cardiogenic shock? (Cardiac)

A

Narrowed Pulse Pressure
Chest Pain
Dysrhythmias
Extra Heart Sounds (S3 S4)

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30
Q

What is unique about a patient in Cardiogenic shock? (Respiratory)

A

crackles d/t pulmonary congestion

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31
Q

What kind of patient does a Cardiogenic shock pt resemble?

A

Heart Failure Patient

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32
Q

After oxygenation, what is the next intervention for a patient experiencing Cardiogenic Shock?

A

Correct the underlying problem by restoring blood flow and reducing the workload of the heart

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33
Q

What are ways to reduce the workload of the heart?

A

Beta Blockers, CCBs, Digoxin, Morphine

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34
Q

What are way to restore blood flow?

A

Thrombolytics, Angioplasty, Stents, CABG

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35
Q

What labs need to be monitored for a patient experiencing Cardiogenic shock?

A

Troponin
CKMB
BNP

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36
Q

What DX tests should be ran for a patient experiencing cariogenic shock?

A

EKG
ECHO
Chest XR

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37
Q

Dobutamine

Dopamine

A

Improves SV, CO

Improves contractility

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38
Q

How must Dobutamine and Dopamine be given?

A

In a central line

Titrated drip, weight based

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39
Q

What is a possible side effect of Dobutamine and Dopamine?

A

Dysrhythmia

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40
Q

Nitroglycerin

A

Systemic Vasodilation

Reduces preload and after load to decrease the hearts O2 demands

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41
Q

What are side effects of Nitroglycerin?

A

Flushed, warm skin

Headaches (indicate good perfusion)

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42
Q

Examples of Circulatory Assist Devices

A

IABP (decrease workload, decrease SVR)

VAD (heart transplant)

43
Q

Nursing Management for a patient experiencing Cardiogenic Shock

A
  1. Oxygen
  2. Hemodynamic monitoring
  3. Vitals, cardiac monitor
  4. PIV, labs, EKG, Chest XR, Echo
  5. Administer meds
  6. Prep for procedure
  7. Enhance safety and comfort
44
Q

What type of shock: Decreased intravascular volume

A

Hypovolemic

45
Q

Absolute Hypovolemia

A

Fluid comes up and out

Loss of intravascular fluid volume

46
Q

Causes of Absolute Hypovolemia?

A 
N/V
Hemmorhage
Diarrhea
Diuresis
Diabetes Mellitus - Polyuria
Diabetes Insipidus - Lack of ADH
47
Q

Relative Hypovolemia

A

Fluid volume moves from intravascular space to extravascular space
third spacing

48
Q

Causes of Relative Hypovolemia?

A

Burns
Ascites
Internal Bleeding
Massive Vasodilation (sepsis)

49
Q

What % of total blood volume must be lost before s/s of shock appear?

A

15%

~ 750mL

50
Q

Will patients with chronic illness show s/s of shock sooner or later than a healthy patient?

A

Sooner

51
Q

Will Elderly patients and Children show s/s of shock sooner or later?

A

Sooner

52
Q

What’s unique about a patient experiencing Hypovolemic shock? (skin)

A 
Third Spacing (ascites)
Trauma
53
Q

What’s unique about a patient experiencing Hypovolemic shock? (GI)

A

Vomiting, Diarrhea

Bloody stools, Emesis

54
Q

Primary nursing intervention for a patient experiencing Hypovolemic shock?

A

OXYGEN

55
Q

What do you do after giving a patient experiencing hypovolemic shock oxygen?

A

Treat the underlying cause

Stop the loss of fluid

56
Q

What do you use to replace the fluid lost during hypovolemic shock?

A 
isotonic fluids (NS, LR)
volume expanders (albumin, dextrans)
57
Q

How many mL of fluid replacement is needed for every 1mL of blood loss

A

3mL

58
Q

If a patient is experiencing hypovolemic shock d/t blood loss what labs need to be monitored?

A

H and H
less than or equal to 7 = think about transfusion

High H and H = fluid loss (not bleeding)

59
Q

If a patient is experiencing hypovolemic shock d/t vomiting and/or diarrhea what labs should be monitored?

A

electrolytes (esp Na+ and K+)

60
Q

Nursing Management of a patient experiencing Hypovolemic Shock?

A 
Hold Pressure, Elevate
Place on Oxygen
Take BP, HR
PIV access, large bore
Administer blood and fluids safely
61
Q

What type of shock:

An insult or injury causes massive vasodilation without compensation because f the loss of SNS constriction

A

Neurogenic

62
Q

Predisposing factors to Neurogenic Shock

A

Spinal Cord Injury (As quick as 30min post)
Spinal anesthesia
Opioids, benzos (depression of the vasomotor center)

63
Q

What’s unique about a patient experiencing Neurogenic shock? (Cardiovascular)

A

Bradycardia and Hypotension caused by massive vasodilation and loss of SNS

64
Q

What’s unique about a patient experiencing Neurogenic shock? (Pulmonary)

A

Depends on the level of the injury

65
Q

What’s unique about a patient experiencing Neurogenic Shock? (Renal)

A

Bladder dysfunction

66
Q

What’s unique about a patient experiencing Neurogenic shock? (Skin)

A

Massive dilation causes warm, dry skin – may progress to take on temp of environment (poikilothermia)

67
Q

The skin takes on the temperature of the environment

A

poikilothermia

68
Q

What’s unique about a patient experiencing Neurogenic shock? (GI)

A

Bowel Dysfunction

69
Q

Medications for patients experiencing Neurogenic Shock

A

Vasopressors

Atropine for bradycardia

70
Q

Nursing Management of Patient Experiencing Neurogenic Shock

A
  1. Maintain Spinal Alignment
  2. Provide O2
  3. Place on monitor
  4. PIV
  5. Meds
  6. Safety and Comfort
71
Q

Cardiovascular support for patient experiencing Neurogenic Shock

A

DVT prophylaxis

72
Q

Neurologic Support for a patient experiencing Neurogenic Shock

A

Monitor for s/s of internal injury

Neurologic status, orientation, LOC, behavioral problems, report any changes

73
Q

What type of shock:

hypersensitivity (allergic) reaction to a sensitizing substance causes quick massive vasodilation

A

Anaphylactic

74
Q

Predisposing factors for Anaphylactic Shock

A 
Exposure to allergen
Contrast dye
Drugs
Chemicals
Vaccines
Food
Insects
Venom
Latex
Anesthesia
75
Q

What’s unique about Anaphylactic Shock?

A

Sudden Onset

76
Q

Nursing priorities for a patient experiencing Anaphylactic Shock

A

Airway and Epinephrine

77
Q

What’s unique about a patient experiencing Anaphylactic shock? (Pulmonary)

A 
SOB
*laryngeal edema*
bronchospasm
wheezing
stridor
may need artificial airway
78
Q

What’s unique about a patient experiencing Anaphylactic shock? (Renal)

A

Incontinence

79
Q

What’s unique about a patient experiencing Anaphylactic shock? (Skin)

A

Flushing
Pruritus
Urticaria
Angioedema (commonly caused by Ace Inhibitors)

80
Q

What’s unique about a patient experiencing Anaphylactic shock? (Neurological)

A

Feeling of impending doom

81
Q

What’s unique about a patient experiencing Anaphylactic shock? (GI)

A

Cramping
Abdominal Pain
N/V/D

82
Q

Medical Management of a patient experiencing Anaphylactic Shock

A

Remove causative antigen
Fluids - aggressive
Medication (Epinephrine IM, Benadryl IV) – both oppose histamine

83
Q

Nursing Management of a patient experiencing Anaphylactic Shock

A
  1. Remove Antigen
  2. Epi IM (vastus lateralis)
  3. HOB up if airway issue, supine if not
  4. Airway - O2 or Intubation
  5. PIV x 2, IV fluids (aggressive isotonic)
  6. Meds
84
Q

What medications are given to a patient experiencing Anaphylactic shock?

A

Albuterol/aerolized epi - reduce laryngeal edema
Benadryl
H2 Blockers - Zantac
Steroids - antiinflammatories

85
Q

What is Sepsis?

A

constellation (group) of symptoms in response to an infection

86
Q

What type of shock: in the presence of sepsis with hypotension despite adequate fluid resuscitation; inadequate tissue perfusion with tissue hypoxia.

A

Septic Shock

87
Q

What’s unique about a patient experiencing Anaphylactic shock? (Cardiovascular)

A 
normal/low-normal BP that responds to fluids (early)
low BP that does not respond to fluids (late)
give meds (vasopressors)
88
Q

What’s unique about a patient experiencing Anaphylactic Shock? (Pulmonary)

A 
Hypoxia (early)
Respiratory Distress (late)
89
Q

If septic shock is not managed early it can progress to ….

A

ARDS

90
Q

What’s unique about a patient experiencing Anaphylactic shock? (Skin)

A

warm and flushed – cool and mottled (late)

91
Q

What’s unique about patient experiencing Anaphylactic shock? (Neurological)

A

Hyperthermia (infection)

Hypothermia (late)

92
Q

FSBS of a patient experiencing Septic Shock

A

elevated b/c liver can’t keep up

93
Q

What is important to collect with a patient experiencing septic shock? (labs)

A

blood cultures
suspected source of infection
lactate level

94
Q

Fluid Challenge

A

administer 30mL/kg isotonic crystalloid fluids for hypotension or lactate >4mmol/L

Q30min

remeasure lactate

95
Q

What do you give for persistent hypotension that does not respond to fluids

A

Vasopressors

norepinephrine

96
Q

Medical Management of a patient experiencing Septic Shock

A 
Antibiotics: broad spectrum within the 1st hour (get blood cultures first)
GI prophylaxis (PPIs)

Blood sugar - goal <180

97
Q

Nursing Management of patient experiencing Septic Shock

A
  1. HOB, up if resp. issue, flat if possible
  2. Oxygen – ear, forehead, bridge of the nose = better perfusion
  3. Vitals, rectal temp is best (more accurate, better perfusion)
  4. PIV
  5. Blood cultures and other labs
  6. Fluids
  7. Antibiotics - starting within first hour decreases mortality rate
  8. Fever treatment (Tylenol, cooling blanket, decrease room temperature, remove covers) – decrease the temperature gradually
    ¥ Hemodynamic status - central lines
    ¥ Reassess temp after Tylenol
    ¥ Collaborate to find source of infection
    ¥
Be aware of risks for all patients
o	Pt w/ multiple invasive lines
¥	Assess fluid/kidney status 
¥	I &amp; O
¥	Daily weights 
¥	Nutritional status
¥	FSBS
98
Q

Sepsis six

A 
oxygen
blood cultures
antibiotics
fluid challenge
lactate
urine output
99
Q

What type of shock: Physical obstruction of blood flow to or from the heart, causes decreased CO

A

Obstructive

100
Q

Complication of any form of shock due to inadequate tissue perfusion
Failure of two or more organ systems

A

MODS

101
Q

Medical Management of MODS

A 
Prevention
Early detection
Control initiating event
Promote adequate organ perfusion
Provide nutritional support

Nursing management similar to septic shock

102
Q

Causes of Obstructive Shock

A

Cardiac Tamponade
Tension Pneumo
Superior Vena Cava Syndrome
Abdominal Compartment Syndrome

103
Q

Presentation of Obstructive Shock

A 
Similar to HF
JVD
Cough
Muffled Heart Sounds
Edema

NURSING (16 decks)

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